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DISEASES    OF    THE    STO^IACH 

AND    THEIR 
SURGICAL    TREATMENT 


The  Normal  Position  or  the  Stomach. 


DISEASES  OF  THE  STOMACH 


AND   THEIR 


SURGICAL  TREATMENT 


A.  W.  MAYO  ROBSON,  F.R.C.S. 

Member  ot   Council  and  Hunterian  Professor  (1897  and  igco),  Royal  College 

OF  Surgeons  of  England  ;  Senior  Surgeon  to  the  General  Infirmary  at 

Leeds  ;  Emeritus  Professor  of  Surgery  in  the  Yorkshire  College  of 

THE  Victoria  University  ;    Consulting  Surgeon   to    the   Keighley 

AND  the  Batley  HOSPITALS;    HoN.  President  of  the   Surgical 

Section     of     the     International    Medical    Congress    at 

Paris,    1900;    Hon.    President    of    the    International 

Gynaecological  Congress  at  Amsterdam,  1899 


B.  G.  A.  MOYNIHAN,  M.S.   Lond.,  F.R.C.S. 

Assistant  Surgeon   Leeds    General    Infirmary;    Arris   and    Gale   Lecturer 

(1899  and  1900)  and  Member  of  the  Board  of  Examiners  in  Anatomy 

FOR  the  Fellowship,  Royal  College  of  Surgeons  of  England  ; 

Consulting  Surgeon,  Skipton  and  District  Hospital; 

Senior  De:wonstrator  of  Anatomy,  Yorkshire 

College,  Leeds 


NEW    YORK 
WILLIAM     WOOD     &     COMPANY 

M  D  C  C  C  C  I 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/diseasesofstomacOOrobs 


OUR  COLLEAGUES  OX  THE  STAFF 

OF    THE 

CxEXERAL  INFIR^IARY  AT  LEEDS 


WORKS  BY  MR.  MAYO  ROB  SON.     . 

A  GUIDE  TO  THE  INSTRUMENTS  AND  APPLIANCES 
REQUIRED  IN  VARIOUS  OPERATIONS. 

Cassell  and  Co. 

ON  GALL-STONES  AND  THEIR  TREATMENT. 
Cassell  and  Co.     1892. 

DISEASES  OF  THE  GALL-BLADDER  AND  BILE- 
DUCTS.     Second  Edition. 

Bailliere,  Tindall  and  Cox.     1900. 


B  Y  MR.  MO  YNIHA  N. 

RETROPERITONEAL  HERNIA. 
Bailliere,  Tindall  and  Cox.     1891 


PREFACE 

There  can,  we  think,  be  no  need  for  an  apologetic  preface 
to  a  work  dealing  with  the  '  Surgery  of  the  Stomach.'  This 
branch  of  our  art  has  made  so  great  advances  within  the  last 
few  years  that  a  review  of  its  progress  seems  both  fitting  and 
desirable. 

The  present  work  took  its  origin  in  the  Hunterian  Lectures 
delivered  by  one  of  us  at  the  Royal  College  of  Surgeons  of 
England  in  igoo.  The  attention  called  to  the  subject  by 
those  lectures  resulted  in  a  large  increase  in  our  experience 
of  the  various  gastric  conditions  amenable  to  surgical  treat- 
ment. To  deal  fully  with  subjects  lightly  touched  upon  in 
the  lectures,  to  expand,  in  fact,  those  lectures  into  a  volume, 
was  a  work  which  the  lecturer  unaided  would  have  been  hard 
pressed  to  accomplish  in  the  space  of  time  within  which  it 
w^as  felt  desirable  to  publish  the '  volume.  A  collaboration 
seemed  therefore  desirable,  and  as  we  had  been  associated  in 
hospital  work  more  or  less  closely  since  1887,  when  our 
relative  positions  were  those  of  Honorary  Officer  and  House 
Surgeon,  the  present  collaboration  seemed  both  natural  and 
appropriate. 

For  every  statement  made  in  the  book  we  jointly  hold 
ourselves  responsible.  The  whole  work  has  undergone  a 
careful  revision  by  both  of  us,  and  much  of  it  has  been 
frequently  discussed  while  in  preparation  and  after  comple- 
tion. 

That  the  aid  of  surgery  must  be    called  in  to  deal   with 


X  PRE FA CE 

both  simple  and  malignant  disease  of  the  stomach,  in  the 
future  far  more  often  than  in  the  past,  seems  inevitable.  We 
consider  that  we  are  justified  in  saying  that  our  joint  record 
shows  that  the  risks  of  such  surger}^  are  far  less  than  has 
been  generally  believed. 

In  support  of  this  statement,  one  of  us,  in  a  series  of  over 
200  operations  on  the  stomach,  can  reter  to  the  last  seventy- 
five  consecutive  operations  in  his  private  clinic,  including 
malignant  and  simple  cases,  with  only  one  death  (and  that 
from  accidental  perforation  on  the  twelfth  day),  and  the  other 
can  point  to  a  consecutive  series  of  forty-seven  hospital  and 
private  cases,  with  three  deaths. 

We  take  this  opportunity  to  thank  Dr.  W.  MacGregor 
Young,  M.A.,  for  his  valuable  assistance  in  illustrating  the 
\\ork  by  original  drawings  and  diagrams,  which  will  be  found 
of  great  service  in  elucidating  the  text,  and  one  of  us  also 
accepts  the  occasion  of  the  preface  to  acknowledge  the  great 
help  he  received  during  the  preparation  of  the  Hunterian 
Lectures  from  Dr.  Farquhar  ^Macrae,  now  on  the  staff  of 
the  Western  Hospital,  Glasgow,  but  at  that  time  assisting 
us  in  his  private  clinical  work. 

A.  W.  M.  R. 

Leeds.  B.  G.  A.  M. 


CONTENTS 

CHAPTER  PAGE 

I.    ANATOMICAL    CONSIDERATIONS DIAGNOSIS          -  -  I 

II.    CONGENITAL    STENOSIS    OF    THE    PYLORUS             -  -  36 

III.  INJURY    OF    THE    STOMACH             -                   -                   -  -  45 

IV.  SIMPLE    TUMOURS    OF    THE    STOMACH     -     '              -  -  52 
V.    CANCER    OF    THE    STOMACH           -                   -                   -  -  60 

VI.    SARCOMA    OF    THE    STOMACH        -                   -                   -  -  84 

VII.    GASTRIC    ULCER                  -                   -                   -                   -  -  89 

VIII.    GASTRIC    ULCER    AND    ITS    COMPLICATIONS             -  -  IO5 

IX.    THE    COMPLICATIONS    OF    GASTRIC    ULCER              -  -  I30 

X.    THE    COMPLICATIONS    OF    GASTRIC    ULCER    {continued)  -  I50 

XI.    THE    COMPLICATIONS    OF    GASTRIC    ULCER    {continued)  -  1 73 

XII.    THE    COMPLICATIONS    OF    GASTRIC    ULCER    {continued)  -  I98 

XIII.  DILATATION    OF    THE    STOMACH    FROM    OTHER    CAUSES  -  2IO 

XIV.  PERIGASTRITIS                     ....  -  222 
XV.    GASTRIC    FISTULA              -                   -                   -                   -  -  233 

XVI.    GASTROPTOSIS  ------  239 

XVII.    TUBERCLE SYPHILIS PHLEGMONOUS    GASTRITIS  -  243 

XVIII.    OPERATIONS    UPON    THE    STOMACH             -                   -  -  253 


SURGERY    OF    THE    STOMACH 

CHAPTER  I 

ANATOMICAL  CONSIDERATIONS— DIAGNOSIS 

The  stomach,  when  normal,  is  a  somewhat  pear-shaped 
hollow  organ  situated  in  the  epigastric  and  left  hypochondriac 
regions,  the  larger  part  (fully  two-thirds)  being  under  cover 
of  the  liver  and  diaphragm,  but  the  anterior  surface  in  its 
lower  part  lying  against  the  anterior  abdominal  wall.  Its 
general  axis  is  not  quite  vertical,  but  inclined  obliquely,  the 
cardiac  orifice  being  on  the  left  of  the  tenth  dorsal  vertebra, 
while  the  pyloric  outlet  is  situated  on  the  right  of  the  eleventh 
or  twelfth  dorsal  vertebra,  about  an  inch  to  the  right  of  the 
middle  line,  and  nearer  the  anterior  abdominal  wall.  The 
channel  of  entrance  into  the  stomach  is  vertical,  but  that  of 
exit  is  directed  downwards,  backwards,  and  to  the  right. 

Between  the  cardiac  and  pyloric  orifices  the  stomach  is 
curved  along  both  its  upper  and  lower  borders.  The  upper 
border,  known  as  the  lesser  curvature,  between  3  and  4 
inches  in  length,  is  slightly  concave,  looks  upward  and 
towards  the  right,  and  is  nearly  all  situated  to  the  left  of 
the  middle  line.  The  greater  curvature  is  about  three  times 
the  length  of  the  lesser,  and,  except  for  a  small  part  near  the 
pylorus,  is  convex  throughout.  Tracing  it  from  the  cardiac 
orifice,  it  is  found  to  arch  upwards  to  the  left  for  about 
2  inches  :  it  then  sweeps  downwards  and  to  the  right  until 
it  reaches  the  middle  line,  where  it  again  changes  its  direc- 
tion and  passes  upwards,  to  the  right  and  slightly  forwards, 
till  it  reaches  the  pylorus.     When  the  stomach  is  filled  with 

I 


2  SURGERY  OF  THE  STOMACH 

air  under  medium  tension,  the  lower  border  reaches  to  ^\•ithin 
i^-  to  2t  inches  of  the  umbihcus.  being  rather  higher  in  women 
than  in  men  (E^^•ald,  "  Diseases  of  the  Stomach,'  p.  115). 

The  onlv  fixed  part  of  the  stomach  is  the  cardiac  orifice, 
^\■hich  hes  at  a  point  on  the  posterior  abdominal  wall  corre- 
sponding in  front  with  the  junction  of  the  seventh  left  costal 
cartilage  with  the  sternum. 

When  the  stomach  is  distended,  its  position  is  somewhat 
altered.  The  greater  curvature  comes  forward,  and  the 
anterior  surface  is  thus  caused  to  look  upward  as  well  as 
to  the  front,  while  the  posterior  wall  faces  downwards  and 
backwards.  The  pylorus,  which  is  freel}'  movable,  is  under 
these  circumstances  usuall}^  displaced  2  or  3  inches  to  the 
right  of  the  middle  line. 

In  its  greatest  length  the  normal  stomach  measures  rather 
over  10  inches,  and  its  diameter  at  its  widest  part  (toward 
the  cardiac  end)  is  between  4  and  5  inches.  The  normal 
capacity  of  the  stomach  \-aries  greath- in  different  individuals, 
but  is  probably  never  more  than  2i  pints  (Ewald,  '  Diseases 
of  the  Stomach,'  p.  120). 

The  ^^■all  of  the  stomach,  which  is  thinner  than  that  of  the 
oesophagus,  though  thicker  than  that  of  the  small  intestine, 
is  composed  of  four  layers — the  serous,  muscular,  submucous, 
and  mucous. 

The  serous  coat  is  composed  of  peritoneum,  which  closely 
invests  the  whole  viscus,  except  at  the  greater  and  lesser 
curvature,  where  the  attachment  is  looser,  allowing  space  for 
the  larger  bloodvessels. 

The  muscular  coat  consists  of  unstriped  muscular  fibres 
arranged  in  three  more  or  less  distinct  layers — longitudinal, 
circular,  and  oblique.  Of  these  three,  that  which  is  of 
special  interest  is  the  middle  layer.  This,  toward  the 
pylorus,  becomes  thicker  and  stronger,  and  when  it  reaches 
the  exit  from  the  stomach  the  circular  fibres  are  heaped  up 
so  as  to  project  inward  into  the  lumen  of  the  passage  and 
form  a  distinct  sphincter.  Under  normal  circumstances 
the  calibre  of  the  pyloric  orifice  has  a  diameter  of  rather 
less  than  half  an  inch.  This  diminution  in  the  calibre  is 
caused  entirely  by  the  increase  of  the  muscular  fibres,  the 


ANA  TOMICAL  CONSIDER  A  TIONS—DIA  GNOSIS  3 

longitudinal  fibres  taking  no  part  in  the  process,  but  passing 
on  into  the  first  part  of  the  duodenum. 

The  submucous  coat  is  composed  of  areolar  tissue,  and  is 
the  tunic  in  which  the  larger  arterioles  break  up.  The  sub- 
m-ucous  tissue  does  not  bind  the  mucous  membrane  very 
closely  to  the  muscular  layer,  but  permits  considerable 
sliding  one  upon  the  other. 

The  mucous  membrane,  which  is  thickest  in  the  pyloric 
region  and  thinnest  in  the  great  sac,  is  richly  supplied  with 
glands.  The  whole  interior  of  the  stomach  is  covered  by  a 
single  layer  of  columnar  epithelial  cells.  Scattered  through- 
out the  mucous  membrane,  but  most  abundant  toward  the 
pylorus,  are  small  masses  of  lymphoid  tissue,  which  are  of 
importance  as  occasionally  ulcerating  in  Hodgkin's  disease. 

The  stomach  receives  its  blood-supply  from  all  three  of 
the  branches  of  the  coeliac  axis.  The  coronary  artery  of 
the  stomach  reaches  the  viscus  at  the  cardiac  end,  and, 
after  giving  off  branches  to  the  lower  part  of  the  oesophagus, 
it  runs  along  the  lesser  curvature  from  left  to  right,  and 
anastomoses  with  the  pyloric  branch  of  the  hepatic  artery. 
From  the  hepatic  artery  two  branches  in  part  aid  the  supply 
of  the  stomach.  The  smaller  of  these,  the  pyloric  branch, 
reaches  the  stomach  at  the  upper  margin  of  the  pylorus, 
and  passes  toward  the  left  along  the  lesser  curvature  to 
inosculate  with  the  terminal  branches  of  the  coronary  artery. 
The  gastro-duodenal  artery  passes  behind  the  first  part  of  the 
duodenum  close  to  the  pylorus,  and,  after  giving  off  the 
superior  pancreatico-duodenal  branch,  continues  from  right 
to  left  along  the  greater  curvature  of  the  stomach  as  the 
right  gastro-epiploic  artery.  The  splenic  artery  runs  along 
the  upper  margin  of  the  pancreas  from  right  to  left,  and 
supplies  several  small  branches  to  the  stomach  before  it 
gives  rise  to  the  left  gastro-epiploic  artery,  which  lies  between 
the  layers  of  the  gastro-splenic  omentum,  and  is  continued 
along  the  great  curvature  of  the  stomach  to  anastomose 
with  the  terminal  branches  of  the  right  gastro-epiploic 
artery. 

From  the  two  arches  thus  formed  at  the  upper  and-  lower 
margins  of  the  stomach,  vessels  pass  at  right  angles  to  supply 

I — 2 


4  SUI^GERY  OF  THE  STOMACH 

the  body  of  the  viscus.  The  ukimate  branches  of  these  form 
an  intricate  network  in  the  interglandular  tissue,  and  from 
the  capillaries  round  the  mouths  of  the  glands  the  veins  take 
origin.  These  in  the  mucous  membrane  are  fewer  but  larger 
than  the  arteries.  They  form  a  plexus  in  the  submucous 
tissue,  and  then  pass  along  with  the  arteries  to  form  larger 
veins  corresponding  to  the  large  arteries  already  described — 
viz.,  coronary,  left  gastro-epiploic,  right  gastro-epiploic,  and 
pyloric  veins.  These  all  empty  into  the  portal  vein,  either 
directly,  as  in  the  case  of  the  pyloric  and  coronary  veins,  or 
by  joining  the  superior  mesenteric  or  splenic  veins. 

The  lymphatics  of  the  stomach,  which  are  very  numerous, 
arise  in  intimate  relation  with  the  gland  tubules.  They  form 
a  plexus  of  dilated  lymph  sinuses  in  the  submucous  tissue, 
and  then  pass  toward  the  upper  and  lower  margins,  where 
they  traverse  a  number  of  lymphatic  glands  which  lie  along 
the  gastric  borders  of  the  small  and  great  omenta  respectively. 
Thence  they  pass  to  the  coeliac  glands,  which  lie  beside  the 
aorta  above  the  origin  of  the  superior  mesenteric  artery, 
those  of  the  lesser  curvature  following  the  course  of  the 
coronary  vessels  until  the  cardiac  orifice  is  reached,  when 
they  turn  down  behind  the  pancreas  to  reach  the  coeliac 
glands.  Those  on  the  greater  curvature  run  with  the  right 
gastro-epiploic  vessels,  and  in  part  with  the  splenic  vessels, 
and  reach  the  same  lymphatic  glands.  Thence  they  pass, 
together  with  the  vessels  which  drain  the  mesenteric  glands, 
to  open  into  the  lower  end  of  the  thoracic  duct. 

The  nerves  of  the  stomach,  derived  from  the  terminal 
branches  of  both  pneumogastrics  and  from  sympathetic 
branches  from  the  solar  plexus,  are  very  abundant,  and 
not  only  account  for  the  very  severe  pain  caused  by  ulcera- 
tion, but  also  for  the  severe  collapse  produced  by  injury, 
though  it  is  a  mistake  to  suppose  that  manipulation  of  the 
pylorus  is  always  attended  by  the  severe  shock  suggested  by 
the  experiments  made  by  Dr.  Crile ;  for  in  many  cases  we 
have  freely  handled  the  stomach  and  pylorus,  and  operated 
on  them  without  our  patient  experiencing  more  shock  than 
would  be  expected  after  any  abdominal  operation.  When 
the  pylorus  is  adherent   and   the   parts   have   to   be   much 


A  NA  TO  MIC  A  L  CONSIDER  A  TIONS—DIA  GNO  SIS  5 

dragged  on,  severe  shock  is  not  infrequently  seen,  but  this  is 
due  to  interference  with  the  large  sympathetic  nerves  and 
ganglia  behind  the  pylorus. 

The  relation  of  the  sympathetic  nerves  with  the  seventh, 
eighth  and  ninth  spinal  roots  accounts  for  the  superficial 
tenderness  of  the  epigastrium  in  ulceration,  and  for  the 
reflected  left  shoulder-blade  pain.  This  is  well  shown  in 
pyloric  adhesions  complicating  cholelithiasis,  where,  though 
the  pain  is  originally  on  the  right,  passing  to  the  right  infra- 
scapular  region,  as  soon  as  the  pylorus  becomes  involved  in 
the  inflammation  or  tied  down  by  adhesions,  the  pain  passes 
also  to  the  left  subscapular  region. 

The  anterior  surface  of  the  stomach  is  in  relation  above 
with  the  under  surface  of  the  left  lobe  of  the  liver  and  the 
diaphragm,  and  below  with  the  abdominal  parietes  opposite 
the  epigastric  region.  The  posterior  surface  rests  upon  the 
transverse  meso-colon,  behind  which  are  the  pancreas  and 
great  vessels. 

Above,  the  stomach  is  connected  to  the  liver  by  the  g^^astro- 
hepatic  omentum,  in  the  free  (right)  border  of  which  run  the 
common  bile-duct,  the  portal  vein,  and  the  hepatic  artery. 
To  the  left  of  the  cardiac  orifice,  between  the  oesophagus  and 
diaphragm,  is  a  small  fold  of  peritoneum,  the  gastro-phrenic 
omentum. 

The  gastro-splenic  omentum  lies  at  the  extreme  left  of  the 
stomach,  but  is  of  more  importance  in  the  surgery  of  the 
spleen  than  of  the  stomach. 

The  great  omentum  is  attached  to  the  whole  lower  surface 
of  the  stomach,  from  which  it  passes  down  over  the  trans- 
verse portion  of  the  colon. 

The  above  description  applies  to  the  normal  stomach,  but 
there  is  probably  no  organ  in  the  body  which  varies  so  much 
in  size,  position,  and  relations  under  pathological  circum- 
stances. 

It  may  be  so  contracted,  as  in  some  cases  of  cancerous  or 
simple  stricture  of  the  oesophagus,  as  to  lie  quite  away  from 
the  surface  and  be  tucked  under  the  liver  and  ribs,  forming 
little  more  than  a  thick-walled  tube  ;  on  the  other  hand,  in 
some  cases  of  stenosis  of  the  pylorus,  it  may  be  so  dilated  as 


6  SURGERY  OF  THE  STOMACH 

to  occup}'  every  region  of  the  abdomen,  reaching  even  behind 
the  pubes  into  the  true  pehis. 

The  pylorus,  instead  of  readily  permitting  passage  of  the 
forefinger,  may  be  so  contracted  as  barely  to  admit  a  No.  6 
catheter,  and  cicatricial  contraction  in  the  body  of  the 
stomach  may  so  reduce  its  calibre  at  a  particular  point  as  to 
render  it  less  than  that  of  the  normal  pylorus. 

The  free  border  of  the  lesser  omentum  may  be  so  shortened 
as  to  anchor  the  pylorus  higher  up  than  normal,  and  as  a 
consequence  of  ulceration  the  pylorus  or  other  part  of  the 
stomach  may  be  fixed  to  the  parietes  or  to  neighbouring 
organs  in  such  a  way  as  seriously  to  interfere  with  the  gastric 
functions ;  or  the  lesser  omentum  may  be  so  wide  as  to  allow 
the  stomach  to  descend  well  below  the  umbilicus,  as  in 
Glenard's  disease,  and  under  such  circumstances  the  pancreas 
can  be  easily  felt,  and  when  the  abdomen  is  opened  even  seen 
above  the  lesser  curvature  of  the  stomach. 

At  a  meeting  of  the  Royal  Academy  of  Medicine  in 
Ireland,  February  2,  1900,  Professor  Birmingham  gave  a 
demonstration  of  the  form,  position,  and  relations  of  the 
stomach  as  seen  in  bodies  which  have  been  hardened  by 
intravascular  injections  of  formalin.  The  chief  points  upon 
which  he  dwelt  were :  That  the  empty  stomach  is  con- 
tracted, not  collapsed,  its  pyloric  portion  resembling  thick- 
walled  small  intestine  ;  its  cardiac  portion  rounded,  but 
attenuated  ;  its  surfaces  looking,  the  one  up,  the  other  down, 
and  its  long  axis  nearly  horizontal.  In  this  condition  it  rests 
on  the  '  stomach  bed,'  occupying  only  the  lower  part  of  the 
'  stomach  chamber,'  the  upper  part  of  this  space  being 
occupied  by  the  great  omentum  and  the  transverse  colon, 
which  double  up  over  the  empty  stomach  and  lie  between 
it  and  the  diaphragm.  The  large,  flattened,  and  collapsed 
stomach,  with  anterior  and  posterior  walls  in  contact,  usually 
described  and  pictured,  is  not  found  in  the  hardened  body. 
Three  stages  are  recognised  in  passing  from  the  empty  to  the 
distended  condition.  In  the  first  the  fundus  and  cardiac 
portions  are  expanded,  the  pyloric  portion  remains  con- 
tracted, and  the  lesser  curve  sharply  bent,  as  in  the  empty 
state ;  in  this  stage  the  stomach  resembles  a  Florence  flask, 


A  NA  TO  MICA  L   CONSIDER  A  Tl  ONS—DIA  GNO  SIS  7 

strongly  bent  at  the  junction  of  neck  and  body.  In  the 
second  stage  the  cardiac  portion  is  further  expanded,  and  the 
pyloric  portion  opens  out,  but  the  junction  between  the  two 
is  distinctly  marked.  In  the  third  stage  there  is  an  enlarge- 
ment of  all  the  axes  of  the  organ ;  the  distinction  between 
pyloric  and  cardiac  parts  is  almost  lost ;  the  pylorus  is  carried 
an  inch  or  two  to  the  right  of  the  middle  line,  and  the  antrum 
pylori  is  developed.  But  in  all  these  changes  there  is  no 
rotation  around  the  long  axis  of  the  organ,  with  a  raising  up 
of  the  great  curvature,  etc.,  as  commonly  described.  The 
distended  stomach  lies  obliquely,  its  long  axis  running  from 
the  fundus,  not  vertically,  as  we  have  been  taught  in  recent 
times,  but  inwards  and  downwards  at  an  angle  of  about  40  to 
45  degrees  with  both  the  horizontal  and  mesial  planes. 

Diagnosis. 

Although  diseases  of  the  stomach  naturally  come  under 
the  notice  of  the  physician  at  first,  the  time  has  passed  when 
the  surgeon  can  feel  content  to  accept  and  act  on  the  diagnosis 
already  made  for  him  by  his  medical  colleague,  leaving  with 
the  latter  the  responsibility  of  a  possible  error ;  rather,  he 
must  himself  go  over  the  whole  of  the  medical  evidence,  and 
be  prepared  to  supplement  it  by  surgical  methods,  should 
such  be  required  to  elucidate  the  case  or  to  render  possible 
an  accurate  diagnosis. 

The  diagnosis  of  any  case  of  gastric  trouble  necessitates 
both  a  general  and  a  special  inquiry.  The  former,  which 
involves  the  questions  of  age,  sex,  occupation,  habits,  mental, 
moral,  and  physical  condition,  and  the  history  both  of  the 
patient  and  the  disease,  can  be  best  discussed  when  con- 
sidering the  special  disease ;  the  latter  includes  a  considera- 
tion of  all  the  information  which  the  surgeon  can  elicit  by  a 
physical  examination. 

Inspection. — Inspection  will  always  constitute  our  first 
effort  in  diagnosis,  and  it  is  important  that  the  patient 
should  be  in  the  dorsal  decubitus,  lying  comfortably  in 
a  warm  and  light  room  with  the  abdomen  exposed  to  view. 
Dilatation  of  the  stomach  can  often  be  ascertained  by 
inspection,  and  it  may  in  extreme  cases  be  seen  to  occupy 


8  SURGERY  OF  THE  STOMACH 

every  region  of  the  abdomen.  If  the  dilatation  is  atonic, 
the  swelling  persists  without  visible  peristalsis ;  but  if  it 
is  due  to  narrowing  of  the  pylorus,  visible  peristalsis  from 
left  to  right  can  frequently  be  plainly  seen.  Tumours  of 
the  pylorus  and  of  the  body  of  the  stomach  are  frequently 
visible  through  the  abdominal  wall,  and  in  an  early  stage 
they  may  be  seen  to  move  downwards  on  inspiration  ;  this 
more  especially  applies  to  cases  of  cancer,  since  in  tumours 
depending  on  ulcer  of  the  pylorus  adhesions  form  early,  and 
fix  the  stomach  under  cover  of  the  liver.  Inspection  will 
reveal  the  shallow,  rapid,  costal  breathing  induced  by  pain 
at  the  commencement  of  peritonitis,  and  by  distension  in 
the  later  stages,  just  as  it  will  demonstrate  the  sighing 
respiration  in  internal  haemorrhage,  and  the  irregular,  catch- 
ing breathing  in  diaphragmatic  peritonitis  or  subphrenic 
abscess.  It  will  show  the  fixed  and  bulging  ribs  in  sub- 
phrenic abscess,  and  the  swelling  in  the  upper  abdominal 
region  when  the  pus  tends  to  make  its  way  forwards. 

Palpation. — Palpation  immediately  follows  inspection,  and, 
of  all  methods  which  are  adopted  for  diagnosis,-  it  is  the  one 
which  we  can  least  afford  to  omit.  With  the  patient  supine 
in  bed  or  on  a  couch,  the  head  slightly  elevated  on  a  cushion, 
and  the  knees  drawn  up,  the  muscles  of  the  abdomen  are 
relaxed  as  much  as  possible.  They  can  then  easily  be  kept 
relaxed  by  talking  to  the  patient,  so  as  to  divert  his  attention. 
The  flat  warm  hand  placed  on  the  abdomen  at  once  per- 
ceives any  irregularity  or  abnormality.  If  the  upper  abdo- 
men is  rigid,  it  will  raise  the  suspicion  of  local  peritonitis, 
especially  if,  in  addition,  there  is  tenderness  on  pressure. 
Should  there  be  a  tumour,  its  nodular  character,  if  malignant, 
will  easily  be  felt ;  and  if  it  be  cancer  of  the  pylorus  in  an 
early  stage,  it  will  in  all  probability  be  freely  movable. 
If  there  be  malignant  disease  of  the  body  of  the  organ, 
the  tumour  will  move  downward  on  inspiration,  but  usually 
not  freely  from  side  to  side,  though  w^e  have  seen  a  growth  of 
the  centre  of  the  stomach  forming  an  hour-glass  contraction 
as  freely  movable  as  a  pyloric  tumour  sometimes  is. 

It  will  be  found  better,  as  a  rule,  to  slide  the  hand  over  the 
abdomen,  and  not  to  raise  it  from  the  surface,  thus  avoiding 


A  NA  TO  MICA  L  CONSIDER  A  TIONS—DIA  GNO  SIS  9 

fresh  defensive  contraction  of  the  muscles,  which  will  occur 
if  the  hand  be  raised  and  replaced  on  the  abdomen.  It  may 
sometimes  be  advisable  to  employ  gentle  massage  in  order  to 
elicit  the  presence  of  a  tumour  of  the  body  of  the  stomach,  or 
a  swelling  of  the  pylorus  due  to  muscular  spasm,  as  in  pyloric 
stenosis.  In  some  cases  of  ulcer  a  distinct  tumour  may  be 
present  at  one  time,  owing  to  the  contraction  of  the  muscular 
coat,  and  absent  at  another,  the  tumour  only  being  distinctly 
felt  when  the  spasm  is  present.  In  diagnosing  between 
atonic  dilatation  of  the  stomach  and  that  due  to  obstructed 
pylorus,  the  vermicular  contractions  felt  under  the  palpating 
hand  are  of  the  first  importance.  Where,  as  occasionally 
happens,  palpation  is  difficult  on  account  of  rigidity  of  the 
muscles  or  of  obesity,  an  examination  under  an  anaesthetic 
may  be  advisable.  Bimanual  examination,  with  one  hand  in 
the  loin  and  the  other  on  the  surface  of  the  abdomen,  will 
frequently  give  increased  information  as  to  the  size  of  the 
tumour. 

A  tender  and  rigid  epigastrium  suggests  ulcer  of  the 
stomach,  and  the  situation  of  the  tenderness  is  frequently 
a  good  guide  to  the  site  of  the  ulcer  ;  for  instance,  if  the 
tenderness  be  under  the  left  costal  margin  and  the  left  rectus 
be  rigid,  especially  if  the  patient  be  relieved  by  assuming  the 
dorsal  decubitus,  in  all  probability  the  ulcer  will  be  on  the 
anterior  surface,  whereas  if  the  tenderness  is  on  the  right  of 
the  middle  line,  between  the  umbilicus  and  the  right  costal 
margin,  the  probability  is  that  the  pylorus  is  the  affected 
part.  When  there  are  symptoms  of  ulceration  without 
marked  epigastric  tenderness  and  with  increase  of  pain 
on  dorsal  decubitus,  and  relief  is  found  by  lying  on  the 
face,  the  probability  is  that  the  ulcer  is  on  the  posterior 
wall  of  the  stomach. 

Palpation  will  usually  bring  out  the  character  of  the 
tumour  as  to  hardness  and  softness,  smoothness  or  irregu- 
larity. A  nodular  character  of  the  tumour,  especially  if 
associated  with  fluid  in  the  peritoneal  cavity,  usually  indi- 
cates malignant  disease. 

Pulsation  in  an  epigastric  tumour  is  often  felt,  but  if  the 
growth  is  due  to  cancer  it  will  be  non-expansile. 


10  SURGERY  OF  THE  STOMACH 

Fixation  of  a  tumour  is  suggestive  of  antecedent  peri- 
gastritis, especially  if  tenderness  be  present ;  but  it  may 
also  be  dependent  on  infiltration  due  to  malignant  disease. 
While  palpating  the  abdomen,  it  is  important  to  distinguish 
between  surface  tenderness,  which  may  be  reflected,  and 
deep  pain,  directly  due  to  the  disease  which  is  being  sought 
for.  \  change  of  posture  may  then  be  useful ;  for  instance, 
with  the  patient  on  his  left  side  a  pyloric  tumour  will 
frequently  change  its  position  considerably — especially  is 
this  so  in  the  early  stages  of  pyloriccancer.  Or,  by  making 
the  patient  assume  the  knee-elbow  position,  it  ma}'  be  more 
easy  to  distinguish  and  locate  a  small  tumour  at  the  pylorus 
or  on  the  anterior  surface  of  the  stomach,  as  in  this  position 
the  mass  may  be  more  readily  felt  by  the  hand  placed  flat  on 
the  upper  abdomen  than  with  the  patient  lying  on  his  back. 

A  modification  of  palpation  is  succussion,  which  is  of  con- 
siderable use  in  determining  the  presence  of  a  splash  in  a 
dilated  stomach.  It  may  be  safely  asserted  that  if  the 
stomach  splash  can  be  obtained  habitually  three  hours  after 
a  meal  the  stomach  is  abnormally  dilated.  No  succussion 
splash  should  ever  be  obtained  two  hours  after  a  test  break- 
fast or  five  hours  after  a  full  meal,  otherwise  there  is  motor 
insufficiency,  which  may  be  confirmed  by  washing  out  the 
stomach  and  finding  remnants  of  the  meal. 

The  motility  of  the  stomach  is  seriously  affected  by  organic 
disease,  but  not  b}^  neuroses. 

Palpation  of  the  stomach  may  be  made  more  distinct  by 
distending  the  cavity  of  the  stomach  with  gas.  In  this  way 
one  can  diagnose  hour-glass  contraction,  as  well  as  ordinary 
dilatation,  and  can  estimate  the  size  of  the  cavity  or  cavities. 

In  subphrenic  abscess  on  the  right  side,  palpation  will 
show  if  the  liver  is  depressed,  and  this  will  form  a  link  in  the 
chain  of  evidence  going  to  show  that  the  abscess  is  between 
the  liver  and  diaphragm,  and  not  in  the  liver  itself. 

Percussion. — -Deviation  from  the  normal  size  of  the  stomach 
can  usuall}'  be.  ascertained  by  percussion,  first  with  the  patient 
recumbent,  and  afterwards  by  mapping  out  the  region  of 
dulness  when  the  patient  is  erect  after  he  has  drunk  freely  of 
water.     After  distending  the  stomach  with  gas,  either  through 


ANA  TOMICAL  CONSIDER  A  TIOXS—DIA  GNOSIS  1 1 

a  tube  introduced  through  the  mouth  or  by  giving  a  dose  of 
carbonate  of  soda  in  solution,  followed  by  one  of  tartaric 
acid,  percussion  readily  demonstrates  the  outlines  of  the 
stomach,  and  shows  the  position  of  any  tumour  both  \\-ith 
regard  to  the  orifices  and  to  the  greater  or  lesser  curvature ; 
and  it  also  enables  the  diagnosis  to  be  made  between  a 
pancreatic  and  a  gastric  tumour. 

Percussion  is  also  of  use  in  demonstrating  the  presence  of 
free  fluid  in  the  peritoneal  cavity  due  to  the  rupture  of  a 
gastric  ulcer,  and  for  showing  the  absence  of  liver  dulness 
under  the  like  circumstance  when  sufficient  free  gas  is 
present  in  the  peritoneal  cavity. 

It  must  not,  however,  be  forgotten  that  dulness  in  the 
flanks  ma}-  be  dependent  on  distension  of  the  colon  with 
fluid,  and  the  similarity  to  free  fluid  in  the  peritoneum  may 
be  accentuated  by  change  of  posture,  increasing  the  dulness 
in  the  dependent  area  and  creating  resonance  in  the  elevated 
area.  Again,  resonance  in  the  flanks  may  be  created  by 
distension  of  the  colon  with  gas,  and  excessive  distension  of 
the  colon  may  lead  to  error  in  diagnosis  by  pushing  the  liver 
well  under  cover  of  the  diaphragm,  thus  leading  to  the  belief 
that  the  liver  dulness  is  abolished  by  free  gas  in  the  peritoneal 
cavity.  We  have  known  this  to  occur  in  a  case  of  ruptured 
extra-uterine  gestation  which  was  thought  to  be  one  of 
rupture  of  a  gastric  ulcer. 

Where  a  tumour  is  manifest  to  inspection  or  rendered 
evident  by  palpation,  percussion  is  useful  in  eliciting  the 
presence  of  a  hollow  viscus  in  front  of  it,  as  in  diagnosing 
between  a  pancreatic  and  a  gastric  tumour  ;  for  in  the  former 
case  light  percussion  will  give  resonance  in  front  of  the 
tumour,  whereas  in  the  latter  light  percussion  will  reveal 
dulness. 

Auscultation. — Auscultation  is  of  much  more  importance  in 
the  diagnosis  of  chest  than  of  abdominal  conditions,  but  it  is 
sometimes  useful  in  demonstrating  the  splashing  sounds  in 
gastric  dilatation,  and  the  gurgling  or  metallic  sounds  in 
subphrenic  abscess  containing  gas.  In  the  diagnosis  of 
stricture  of  the  cesophagus,  where  gastrostomy  is  in  question, 
the  gurgling  sound  on  fluid  reaching  the  stomach  is  usually 


12  SURGERY  OF  THE  STOMACH 

delayed  several  seconds  in  the  presence  of  a  constriction. 
Before  performing  gastrostomy  it  is  of  the  first  importance  to 
be  certain  of  the  diagnosis.  Dr.  Ogston  has  pointed  out  that 
in  a  healthy  person  food  occupies  about  four  seconds  in 
passing  from  the  mouth  to  the  stomach,  and  that  if  the  ear 
be  placed  3  inches  below  the  angle  of  the  left  scapula  an 
amphoric  rushing  sound  is  heard  when  fluid  enters  the 
stomach.  But  when  there  is  a  stricture  of  the  gullet,  it  will 
usuall}-  be  found  that  fourteen  or  sixteen  seconds  elapse 
before  fluid  reaches  the  stomach.  This  is  a  valuable  addition 
to  the  ordinary  well-known  means  of  diagnosis. 

In  this  connection  it  may  be  pointed  out  that  spasm  of 
the  pharynx  or  of  the  oesophagus  at  times  closely  resembles 
organic  stricture ;  hence,  it  may  sometimes  be  necessary  to 
make  an  examination  with  the  patient  ansesthetized.  In 
estimating  the  size  of  the  stomach  by  percussion,  greater 
precision  may  be  obtained  by  the  observer  applying  the 
mouth  of  a  stethoscope  over  the  stomach  while  an  assistant 
performs  the  percussion,  when  the  altered  note  is  readily 
recognised  on  the  borders  of  the  stomach  being  pressed. 

Pain. — Though  pain  may  be  absent  in  some  few  examples, 
it  is  present  at  some  stage  of  the  disease  in  the  greater 
number  of  stomach  ailments  calling  for  surgical  treatment, 
and  its  character  and  course  frequently  afford  the  most 
valuable  means  at  the  disposal  of  the  surgeon  for  interpreting 
and  diagnosing  ailments  which  present  few  physical  signs. 

The  history  of  the  onset  of  pain  may  show  the  local  origin 
of  more  general  trouble.  For  instance,  in  the  diffused  pain 
of  general  peritonitis  due  to  the  rupture  of  a  gastric  ulcer  it 
is  of  the  utmost  importance  to  know  whether  it  was  preceded 
by  pain  after  food  and  by  epigastric  tenderness,  so  that  an 
exploration  of  the  abdomen  may  be  made  over  the  site  of  the 
disease,  and  thus  a  great  saving  of  time  effected  in  the 
operation.  In  one  case  of  ruptured  gastric  ulcer  that 
Mayo  Robson  operated  on,  there  were  absolutely  no 
previous  symptoms  of  stomach  disorder,  and,  thinking  from 
the  profound  collapse,  the  sudden  onset,  the  presence  of 
fluid  in  the  abdominal  cavity,  and  the  history  of  a  missed 
period  followed  a  fortnight  later  by  irregular  uterine  bleeding, 


A  iVA  TO  MICA  L  CONSIDER  A  TIONS—DIA  GNO  SIS  1 3 

that  the  case  was  one  of  ruptured  extra-uterine  gestation,  the 
first  incision  was  made  above  the  pubes. 

As  a  rule,  however,  the  pain  from  perforated  gastric  ulcer, 
though  ultimately  diffused,  will  have  been  first  felt  in  the 
epigastrium,  and  the  history  will  disclose  the  past  existence 
of  pain  after  the  ingestion  of  food,  and  probably  indigestion 
of  long  standing ;  there  will  also  frequently  be  a  historv  of 
reflected  pain  in  the  left  scapular  region,  though  in  some 
cases  of  pyloric  ulceration  with  adhesions  to  the  gall-bladder 
and  liver  we  have  found  the  pain  reflected  to  the  right 
scapular  region. 

Obscure  recurrent  abdominal  pains  may  be  dependent  on 
a  stricture  or  kink  at  the  pylorus  produced  by  adhesions, 
which,  though  not  sufficient  to  cause  obstruction,  may  pro- 
duce considerable  distress  and  disability.  In  this  class  of 
cases  the  local  and  reflected  pain  frequently  affords  much  help. 

Instrumental  Aids  to  Diagnosis. — In  subphrenic  abscess  the 
exploring  syringe  affords  useful  aid  in  diagnosing  the  presence 
of  pus  and  enabling  the  surgeon  to  decide  on  the  exact  site 
of  the  incision  for  its  evacuation. 

CEsophageal  bougies  are  emplo3'ed  in  cases  of  dysphagia, 
not  only  for  treatment,  but  to  ascertain  the  site  of  the 
obstruction  and  its  nature,  when  the  question  of  gastrostomv 
arises.  We  prefer  instruments  made  after  the  pattern  of 
bougies  a  boiile  employed  in  urethral  cases  ;  they  are  not 
generally  known,  but  they  present  great  advantage,  both  in 
the  ease  and  safety  with  which  they  can  be  utilized,  and  the 
facility  with  which  they  can  be  employed  to  dilate  a  stricture. 
Messrs.  Rauschke,  of  Leeds,  made  the  first  set  some  years 
ago,  and  they  have  since  copied  them  for  other  surgeons. 

In  a  case  of  starvation  from  stricture  of  the  oesophagus,  the 
question  of  gastrostomy  has  to  be  considered ;  but  it  must 
first  be  shown  that  the  disease  is  incapable  of  being  overcome 
by  other  means.  Simple  stricture,  which  is  a  rare  condition, 
may  frequently  be  efficiently  treated  by  dilatation.  Cancerous 
stricture,  on  the  other  hand,  cannot  be  safely  dilated,  and 
will  require  other  treatment.  If  there  be  a  history  of  steady 
loss  of  flesh  and  gradually  increasing  dysphagia  in  a  middle- 
aged  or  elderly  patient,  malignant  stricture  will  be  suspected; 


14  SURGERY  OF  THE  STOMACH 

and  if  on  passing  a  bougie  it  be  arrested  just  before  entering 
the  stomach,  the  diagnosis  is  rendered  very  probable  ;  while 
if  there  be  slight  bleeding  caused  by  the  gentle  use  of  the 
bougie,  little  doubt  can  be  left. 

Spasm  is  most  frequent  in  the  pharynx,  though  it  may 
occur  in  any  part  of  the  gullet.  It  usually  occurs  in  subjects 
younger  than  those  who  are  affected  by  malignant  stricture, 
and  nearly  always  in  women.  It  is,  however,  frequently 
associated  with  other  nervous  symptoms,  it  varies  in  in- 
tensity, and  it  usually  yields  to  the  passage  of  bougies  without 
difficulty.  If,  however,  a  bougie  cannot  be  passed  in  any 
case  where  spasm  is  suspected,  an  anaesthetic  will  at  once 
settle  the  doubt,  as  under  its  influence  a  full-sized  bougie 
usuallv  reaches  the  stomach  when  the  stricture  depends  on 
spasm  alone.  It  is  noteworthy  that  in  cases  of  spasm  the 
larger  sizes  of  bougies  are  more  likely  to  pass  than  the 
smaller,  while  in  organic  stricture  the  exact  opposite  holds 
good. 

Electric  illumination  may  sometimes  be  useful.  It  is 
accomplished  by  an  apparatus  consisting  of  a  small  electric 
lamp,  fixed  to  the  end  of  a  bougie,  which  is  passed  into  the 
stomach.  If  the  stomach  is  full  of  water,  an  illuminated  area 
is  seen,  which  corresponds  exactly  to  the  limits  of  the  organ. 
It  is  best  demonstrated  in  the  erect  posture  and  in  a  dark 
room.  In  this  way  abnormal  dilatation  of  the  stomach  can 
be  detected,  and  a  tumour  appears  as  a  dark  spot  in  the  light 
field. 

With  regard  to  the  Rontgen  rays,  we  have  found  both  the 
screen  and  the  skiagram  of  use  in  demonstrating  the  position 
of  impacted  coins,  metallic  anastomosis  buttons,  and  other 
foreign  bodies.  The  Rontgen  rays  have  also  been  suggested 
for  localizing  the  position  and  size  of  the  pyloric  orifice,  after 
letting  the  patient  swallow  balls  of  different  sizes  made  of 
bismuth  nitrate  or  carbonate  coated  with  keratin,  which  will 
be  only  temporarily  arrested  at  the  pylorus  if  it  be  patent, 
and  the  keratin  covering  of  which  will  be  dissolved  on 
reaching  the  intestine,  keratin  not  being  soluble  in  the  gastric 
juice.  The  gastro-endoscope  has,  however,  not  yet  proved  to 
be  of  any  material  service  in  diagnosis. 


ANATOMICAL  CONSIDERATIONS— DIAGNOSIS  15 

Vomited  Matters  and  the  Contents  of  the  Stomach. — With 
regard  to  vomit,  the  first  thing  to  consider  is  the  quantity 
vomited  at  one  time.  Nurses  should  be  trained  to  estimate 
this  carefully,  and  also  to  preserve  specimens  on  all  occasions. 
In  dilated  stomach  vomiting  usually  does  not  occur  more 
than  once  daily,  sometimes  only  on  every  second  or  third 
day,  and  the  quantity  at  any  time  is  correspondingly  large. 

In  ulcer  of  the  stomach  a  considerable  portion  of  the  last 
meal  may  be  brought  up  within  an  hour  or  two  of  its  in- 
gestion, and  the  pain  it  has  caused  be  thereby  relieved. 

The  smell  should  also  be  considered,  a  yeasty  smell  being 
characteristic  of  dilatation  of  the  stomach ;  a  habitually 
foetid  odour,  of  cancer  of  the  stomach  ;  and  a  feculent  odour, 
of  intestinal  obstruction. 

Vomit  is  usually  acid  in  reaction  ;  but  it  may  be  alkaline 
in  some  cases  of  chronic  dyspepsia,  or  when  there  is  much 
blood  present. 

The  most  important  abnormal  constituent  of  vomit  is 
blood.  In  large  quantities  its  nature  is  obvious,  and  the 
event  is  suggestive  of  simple  ulcer ;  but  in  cirrhosis  of  the 
liver  profuse  haematemesis  may  occur  owing  to  rupture  of 
dilated  veins.  In  smaller  quantities  the  vomit  has  a  charac- 
teristic dark  appearance,  resembling  coffee-grounds,  and  this 
may  be  due  to  cancer  or  simple  ulcer.  When  the  existence 
of  blood  in  vomited  matter  is  doubtful,  the  most  reliable 
guide  is  the  hsemin  test,  which  may  be  done  in  the  following 
manner: 

Evaporate  a  small  quantity  of  the  gastric  contents  to  dry- 
ness, powder  the  residue  and  place  some  along  with  a  crystal 
of  common  salt  on  a  microscopic  slide,  add  a  drop  of  glacial 
acetic  acid  and  boil  over  a  spirit  lamp,  cover  with  a  cover- 
glass  and  examine  under  a  high  power  for  the  small  dark- 
brown  crystals  of  haemin.  As  a  rule,  it  is  not  necessary  to 
add  sodium  chloride,  since  fresh  blood  contains  sufficient  of 
it ;  but,  since  excess  of  the  salt  does  not  interfere  with  the 
reaction,  it  is  well  to  use  a  crystal  or  two. 

In  cancer  of  the  stomach,  blood  is  frequently  present  in 
the  vomit — often  in  small,  sometimes  in  considerable,,  only 
rarely  in  large  quantity. 


1 6  SURGERY  OF  THE  STOMACH 

Pus  is  sometimes,  but  not  often,  vomited.  In  considering 
both  pus  and  blood  in  a  fluid  said  to  have  been  vomited,  it 
must  be  remembered  that  when  large  quantities  of  fluid  are 
expelled  from  the  lungs — e.g.,  on  the  rupture  of  an  empyema 
into  the  lung  or  a  profuse  haemoptysis — the  sensation  to  the 
patient  is  often  as  if  vomiting  had  occurred.  The  presence 
of  food  and  the  general  absence  of  frothiness  will  help  to 
distinguish  true  vomit,  while  vomited  blood  is  generally  much 
darker  than  blood  from  the  lungs.  But  the  only  reliable  way 
to  make  the  distinction  is  to  inquire  carefully  into  the  facts 
of  the  occurrence.  Pus  in  the  vomit  may  arise  from  an 
empyema  of  the  gall-bladder,  or  a  pancreatic  or  other  abscess 
bursting  into  the  stomach  or  oesophagus. 

Examination  by  the  microscope  of  vomited  material  is 
usually  of  secondary  importance,  but  it  sometimes  affords 
great  assistance,  as  in  the  case  of  a  subdiaphragmatic  abscess 
bursting  into  the  lung  described  on  p.  171,  where  the  presence 
of  half-digested  muscular  fibres  and  the  absence  of  elastic 
tissue  distinctly  proved  the  source  of  the  pus  to  be  from  the 
stomach,  and  not  from  an  abscess  of  the  lung  or  an  empyema, 
and  in  some  cases  of  cancer  where  portions  of  growths  or 
groups  of  cells  are  occasionally  obtained  by  means  of  lavage. 
In  dilatation  of  the  stomach  the  sarcina  ventriculi  is  fre- 
quently to  be  seen,  together  with  yeast  cells.  In  cancer, 
where  macroscopically  there  is  no  evidence  of  blood,  red 
blood  corpuscles  may  often  be  found. 

In  reference  to  the  diagnosis  of  malignant  disease  of  the 
stomach,  the  relative  abundance  or  absence  of  free^ydro- 
chloricacid  has  been  pointed  out  as  being  of  importance  by 
Ewald.  In  order  to  determine  its  existence,  the  patient 
should  take  a  'test  breakfast,'  consisting  of  a  cup  of  weak 
tea  and  a  little  dry  toast.  An  hour  later  the  stomach-tube 
should  be  passed,  and  the  contents  of  the  stomach  drawn  off. 
These  are  to  be  tested  by  Gunsberg's  test  for  free  hydro- 
chloric acid.  The  reagent  consists  of  2  parts  phloroglucin 
and  I  part  of  vanillin  in  30  parts  by  weight  of  absolute 
alcohol.  When  a  few  drops  of  the  filtered  contents  of  the 
stomach  are  evaporated  to  dryness  in  a  porcelain  dish  with 
an  equal  quantity  of  the  reagent,  if  free  hydrochloric  acid  be 


A  NA  TO 311 CA  L  CONSIDERA  TIOXS—DIA  GNO  SIS  1 7 

present  red  cr3"stals  will  form  ;  should  there  be  much  peptone 
present  no  crystals,  but  a  red  paste,  will  result.  The  absence 
or  deficiency  of  free  hydrochloric  acid  occurs  in  several 
morbid  states,  but  its  presence  is  a  strong  point  against  a 
diagnosis  of  malignant  disease  of  the  stomach.  Hyperacidity, 
on  the  other  hand,  is  as  characteristic  of  ulcer  as  diminished 
acidity  is  of  cancer. 

The  mere  presence  of  an  acid  reaction  should  not  be  held 
as  proving  the  presence  of  free  hydrochloric  acid,  since  this 
may  be  caused  by  acid  salts  or  by  free  organic  acids.  Of 
these  latter  the  most  important  is  lactic  acid,  and  it  the  Cj 
practitioner  should  be  able  to  recognise,  since  its  presence  in  / 
appreciable  quantity  in  the  later  stages  of  digestion  is  of 
considerable  diagnostic  import,  implying  as  it  does  that 
excessive  fermentation  is  going  on  in  the  stomach.  It  can 
be  readily  recognised  by  the  use  of  Uffelmann's  reagent, 
which  can  be  made  by  adding  i  drop  of  liq.  ferri  perchlor.  to 
I  ounce  of  a  I  per  cent,  solution  of  carbolic  acid.  This  will 
give  an  amethyst  blue  solution,  the  colour  of  which  is 
changed  to  yellow  on  the  addition  of  the  merest  trace  of 
lactic  acid.  Since  inorganic  acids  decolourize  Uffelmann's 
reagent,  while  sugar,  alcohol,  and  phosphates  give  the  same 
reaction  with  it  as  lactic  acid,  it  is  necessary  to  extract  the 
lactic  acid  by  shaking  the  filtrate,  left  after  filtering  a  small 
quantity  of  gastric  contents,  with  ether,  to  allow  the  ether  to 
separate  from  the  watery  solution,  and  after  decanting  it  to 
evaporate  the  ethereal  solution  until  only  a  few  drops  remain. 
If  any  free  lactic  acid  be  present,  on  adding  some  of  this  to 
Uffelmann's  reagent  the  alteration  in  colour  noted  above  will 
take  place.  The  fatty  acids,  especially  butyric  acid,  give  a 
somewhat  similar  reaction,  but  only  when  present  in  larger 
proportions  than  they  are  found  to  occur  in  the  stomach. 

The  motor  activity  of  the  stomach  has  been  estimated  in 
various  ways,  of  which  two  may  be  mentioned  : 

I.  Leube's  method  consists  in  washing  out  the  stomach  at 
various  times  after  the  administration  of  a  fairly  large  meal — 
a  quarter  of  a  pound  of  freshly  minced  meat  and  some  bread. 
Within  six  or  seven  hours  the  stomach  should  be  empty  ; 
but  in  cases  of  dilatation  of  the  stomach,  or  other  conditions- 

2 


i8  SURGERY  OF  THE  STOMACH 

in  which  the  functional  value  of  the  walls  of  the  stomach  is 
diminished,  some  food  may  be  found  many  hours  after. 

2.  Ewald's  method  depends  on  the  fact  that  salol  does  not 
split  up  in  the  stomach,  but  that  when  subjected  to  the 
action  of  alkaline  pancreatic  juice  it  is  decomposed,  absorbed 
into  the  circulation,  and,  in  part,  excreted  as  salicyluric  acid 
in  the  urine,  where  it  can  be  readily  detected  by  the  addi- 
tion of  neutral  ferric  chloride  solution,  a  violet  coloration 
occurring.  Ewald  ('  Diseases  of  the  Stomach,'  p.  55)  advises 
that  15  grains  of  salol  be  given  along  with  food,  and  the 
urine  tested  at  intervals  thereafter.  Normally,  he  says, 
salicyluric  acid  will  appear  forty  to  sixty — at  most  within 
seventy-five — minutes  after  the  administration  of  the  drug ; 
whereas  in  dilatation  of  the  stomach  its  appearance  will  be 
delayed,  A  simple  method  of  applying  the  test,  devised  by 
Ewald  and  Einhorn  (Einhorn,  '  Diseases  of  the  Stomach,' 
p.  87),  is  to  place  a  drop  of  urine  on  a  filter-paper,  and  then 
let  a  drop  of  10  per  cent,  ferric  chloride  solution  fall  on  the 
moistened  spot.  The  edge  of  the  drop  will  in  the  presence 
of  salicyluric  acid  assume  a  violet  colour. 

Various  ingenious  mechanical  contrivances  have  been 
suggested  for  estimating  the  power  of  the  stomach,  but  these 
appear  to  us  scarcely  to  be  suitable  for  practical  use,  even  if 
the  results  to  be  obtained  from  any  yet  devised  were  certainly 
reliable. 

Examination  of  the  Blood  for  Leucocytosis. — See  p.  70. 
/         Exploratory  Incision. — In  only  a  small  percentage  of  cases 
/       is    simple    exploratory    incision,   as    a    means    of  diagnosis, 
j        necessary,  or  even  justifiable,   and  there   can   be    no  doubt 
'^     but  that  in  some  cases  it  has  served  as  a  cloak  for  careless- 
(^    ness  or  incompetence.     A  careful  physical  examination,  and 
time  and  care  in  studying  the  history  of  the  case,  will  usually 
enable  either  an  exact  diagnosis  or  an  approximate  one  to  be 
made ;    and   in  the  odd  case  the  experienced  surgeon  can 
usually  say  it  is  one  likely  to  be  relieved  only  by  surgical 
treatment,  though  possibly  the  exact  pathological  condition 
may  be  a  miatter  of  some  doubt.     Where  there  is  doubt,  and 
delay  will  not  be  injurious,  a  second  or  even  a  third  examina- 
tion should  be  made,  as  it  is  well  known  that  at  a  second 


ANATOMICAL  CONSIDERATIONS-DIAGNOSIS  19 

visit  new  facts  may  be  brought  to  light,  the  patient's  memory 
may  be  stirred  up,  and  small  data,  really  important,  but 
thought  by  the  patient  or  friends  to  be  too  trivial  to  mention 
at  the  first  visit,  may  form  the  key  to  the  situation  ;  more- 
over, the  mind  of  the  surgeon  may  on  the  next  visit  focus  his 
attention  on  different  points  or  group  his  data  differently>  and 
so  perhaps  arrive  at  a  truer  conclusion.  In  case  of  doubt  a 
consultation  is  advisable,  in  order  that  the  case  may  be 
considered  from  the  point  of  view  of  the  physician.  It 
must  not  be  forgotten,  however,  that  the  surgeon  must 
bear  the  responsibility  that  awaits  the  decision,  and  he 
should  be  careful,  if  a  positive  diagnosis  is  decided  on, 
to  be  able  to  answer  two  questions  in  the  affirmative.  First, 
Can  I  perform  an  exploratory  operation  without  adding 
serious  risk  to  the  life  of  the  patient,  already  threatened 
by  the  disease  ?  Second,  Is  it  possible  that  good  will  result 
from  the  operation  ?  At  times  the  surgeon  may  be  called 
on  to  explore  the  abdomen  for  tumour  of  the  stomach, 
which  it  is  just  possible  may  be  amenable  to  surgical 
treatment,  but  where  it  is  impossible  to  say  beforehand 
whether  the  lymphatic  glands  are  involved,  or  the  disease 
has  invaded  the  adjoining  parts  to  such  an  extent  that  the 
removal  of  the  growth  would  be  useless.  Under  such 
circumstances,  when  the  tumour  is  exposed,  the  great  gift 
(usually  a  matter  of  common-sense  combined  with  experi- 
ence) of  '  knowing  when  to  stop  '  comes  in  ;  for  although 
having  made  an  exploratory  incision  may,  and  probably, 
with  due  precautions,  will,  have  involved  no  risk  to  the 
patient,  any  interference  with  the  tumour  may  inflict  such 
injury  on  the  growth  that  the  surgeon  is  compelled  to 
convert  his  harmless  exploratory  procedure  into  one  of 
•the  most  serious  of  operations,  which,  if  it  does  not  cause 
death  on  the  table  or  shortly  after,  can  lead  to  no  ultimate 
good.  This  is  sheer  meddlesomeness,  and  for  the  credit 
of  surgery,  if  from  no  higher  motive,  should  be  avoided. 

Very  frequently,  however,  when  organic  disease  of  the 
stomach  is  diagnosed,  it  is  impossible  to  decide  what  opera- 
tion is  required  until  the  stomach  is  exposed  and  handled. 
This   applies   very  strongly  to   the    early  stages  of  cancer 

2 — 2 


20  SURGERY  OF  THE  STOMACH 

of  the  stomach,  for  which  operation  in  an  earl}'  stage, 
before  adhesions  have  formed  and  glands  have  become 
affected,  holds  out  the  only  hope  of  cure,  and  also  to  cases 
of  chronic  ulcer  and  to  disabling  adhesions  of  the  pylorus  or 
stomach. 
i  An  exploratory  operation  is  justified  wherever  cancer  of 

^       the  stomach  is  suspected,  for  the  smaller  the  tumour,  the 
greater  will  be  the  hope  of  a  radical  cure. 

In  some  case  of  abdominal  injury,  either  gunshot  or  stab 
J^  wound,  or  even  injury  without  external  wound,  the  severe 
shock,  the  vomiting  of  blood,  and  the  general  condition 
of  the  patient,  may  lead  to  a  suspicion  that  the  stomach 
has  been  injured,  and  an  exploratory  incision  may  be 
justified,  since,  in  case  of  the  stomach  having  been  rup- 
tured, such  an  injury,  if  not  repaired,  would  inevitably  prove 
fatal.     The  following  is  a  case  in  point : 

A  youth  was  admitted  to  the  Leeds  Infirmary  suffering  from 
shock,  with  vomiting  of  blood,  following  on  a  stab  wound  over 
the  stomach.  As  there  was  free  fluid  in  the  peritoneal  cavity, 
it  was  thought  that  bleeding  was  going  on,  arid  that  possibly 
the  stomach  had  been  injured  and  its  contents  had  become  ex- 
travasated.  An  exploration  showed  a  wound  of  the  superior 
mesenteric  vein,  with  bruising,  but  no  wound  of  the  stomach. 
The  vein  was  ligatured  and  the  abdomen  cleared  of  blood,  the 
patient  making  a  good  recovery. 

At  times  all  the  symptoms  of  perforating  ulcer  may  be 
present  without  a  previous  history  of  ulceration,  and  all 
that  can  be  said  is  that  a  peritoneal  catastrophe  has 
occurred  which  threatens  life.  Under  such  circumstances 
an  exploratory  operation  may  be  required.  A  case  of  this 
kind  came  under  the  care  of  Mayo  Robson,  where  a  lady  was 
seized  with  violent  abdominal  pain  at  the  railway-station. 
As  she  became  profoundly  collapsed,  she  was  removed  to 
the  station  hotel,  and  was  seen  by  a  medical  man,  who 
called  a  consultation.  The  only  history  obtainable  was 
that  there  had  been  no  stomach  symptoms,  but  that  the 
patient  had  missed  her  last  menstrual  period  for  nearly  a 
fortnight.  As  there  was  free  fluid  in  the  peritoneal  cavity, 
which  was   thought  to  be  blood  due  to  a  ruptured  extra- 


ANATOMICAL   CONSIDERATIONS— DIAGNOSIS  21 

uterine  gestation,  and  as  the  liver  dulness  was  present,  the 
abdomen  was  opened  above  the  pubes,  when  free  non- 
odorous  gas  escaped,  showing  that  the  case  was  one  of 
ruptured  gastric  ulcer.  The  incision  was  therefore  closed, 
and  another  opening  made  over  the  stomach,  in  which  a 
perforated  ulcer  was  found.  The  perforation  was  closed 
and  the  abdomen  cleansed  by  sponging,  the  patient  making 
a  good  recovery. 

Incision  for  Exposure  of  the  Stomach. — Although  incision  in 
the  middle  line  between  the  xiphoid  and  the  umbilicus  gives 
the  readiest  access  to  the  stomach,  in  some  cases,  especially 
if  there  is  doubt  as  to  what  may  have  to  be  done,  it  is  not 
always  the  best  site,  for  three  reasons  : 

1.  It  is  apt  to  be  followed  by  yielding  of  the  scar  and 
hernia,  unless  long  rest  is  enjoined  after  the  operation. 

2.  The  round  ligament  of  the  liver,  with  its  irregular 
adipose  envelope,  is  apt  to  be  in  the  way  and  to  prove 
confusing. 

3.  To  prolong  the  incision  for  further  investigation  is 
inconvenient,  because  of  the  umbilicus. 

These  difficulties,  of  which  the  first  only  is  of  importance, 
are  obviated  by  an  incision  through  the  inner  margin  of  the 
rectus  muscle  just  to  the  right  or  left  of  the  middle  line. 
An  incision  on  either  side  gives  ample  room  ;  but  if  the 
pylorus  has  to  be  attacked  or  gastro-enterostomy  to  be  done, 
it  is  better  on  the  right  ;  if  gastrostomy  has  to  be  performed, 
it  is  better  on  the  left.  Afterwards,  if  the  abdominal  wall  is 
sutured  layer  by  layer,  there  is  no  fear  of  hernia  or  of  a  weak 
scar  being  left ;  moreover,  there  is  no  difficulty  in  extending 
the  incision  if  more  room  is  required.  For  routine  work  we 
find  the  incision  in  the  middle  line  sufficiently  satisfactory, 
as  it  can  be  very  quickly  performed,  and  with  careful  suturing 
we  have  not  found  it  give  rise  to  subsequent  hernia.  The 
oblique  incision  along  the  costal  margin  is  undesirable, 
because  it  divides  muscle  so  freely,  and  exact  repair  by 
suture  is  difficult ;  hence  permanent  weakness  of  the  abdo- 
minal wall  and  ventral  hernia  are  more  likely  to  occur.  As 
a  matter  of  fact,  with  due  care  in  applying  sutures,  any  one 
of  these  methods  may  be  employed,  and  the  operator  should 


22  SURGERY  OF  THE  STOMACH 

select  that  which  will  give  him  the  best  access  to  the  parts  to 
be  manipulated. 

Gastrotomy. 

Gastrotomy  is  the  term  applied  to  the  operation  of  open- 
ing the  cavity  of  the  stomach.  It  is  one  of  the  oldest 
operations  on  the  stomach,  having  been  practised  by 
Matthis  of  Brandenburg  so  long  ago  as  1602  for  the  removal 
of  a  knife  that  had  been  accidentally  swallowed.  But  as  a 
diagnostic  method  with  a  view  to  further  treatment  gas- 
trotomy is  a  modern  procedure.  Exploratory  gastrotomy 
has  only  been  performed  within  the  last  few  years ;  but  by 
its  means  an  extensive  and  minute  examination  of  the  in- 
terior of  the  stomach  may  be  made  with  thoroughness  and 
safety,  so  that  in  any  case  calling  for  operation,  where  by 
other  means  a  positive  diagnosis  cannot  be  arrived  at,  the 
surgeon  is  justified  in  opening  and  exploring  the  stomach. 
It  will  be  convenient  in  this  place  to  consider  the  operation 
of  gastrotomy  as  a  whole,  bearing  in  mind  that  one  of  its 
purposes  may  be  simply  exploratory. 

It  may  be  performed — 

1.  For  the  removal  of  foreign  bodies  from  the  stomach. 

2.  For  the  removal  of  foreign  bodies  from  the  lower  end 
of  the  oesophagus. 

3.  For  dilating  a  stricture  of  the  oesophagus. 

4.  For  dilating  a  stricture  of  the  pylorus. 

5.  For  the  removal  of  a  polypus  or  other  tumour  project- 
ing into  the  stomach. 

6.  For  exploration  in  case  of  intractable  or  bleeding  ulcer. 

7.  For  curetting  a  cancer  of  the  pylorus,  as  in  Bernay's 
operation. 

The  preliminary  incision  of  the  parietes,  which  has  already 
been  described,  requires  to  be  rather  free  for  gastrotomy. 
After  the  abdomen  has  been  opened,  flat  sponges  or  gauze 
pads  should  be  packed  round  the  stomach,  so  as  to  avoid 
soiling  of  the  peritoneal  cavity.  The  edges  of  the  wound 
having  been  retracted,  the  stomach  can  now  be  palpated ; 
and  if  palpation  from  the  front  does  not  give  the  information 
required,  a  tear  may  be  made  in  the  gastro-colic  omentum. 


GASTROTOMY  23 

SO  as  to  admit  the  fingers  to  palpate  the  posterior  surface. 
The  stomach  should  now  be  drawn  forward,  surrounded  by 
a  sheet  of  sterilized  gauze,  and  opened  by  a  free  incision  in 
its  longitudinal  axis.  Divided  vessels  must  be  seized  and 
ligatured,  and  the  liquid  contents  of  the  stomach  mopped  or 
siphoned  out,  if  they  have  not  been  pushed  on  into  the 
duodenum  before  the  stomach  was  opened.  On  retracting 
the  edges  of  the  gastric  incision,  the  interior  of  the  stomach 
will  be  brought  into  view,  and  may  be  further  explored  by 
the  electric  cystoscope,  if  thought  necessary,  as,  for  instance, 
in  hsematemesis  from  a  small  bleeding  ulcer.  If  the  posterior 
wall  be  the  part  affected,  it  may  be  invaginated  by  the 
fingers,  inserted  through  the  omental  slit,  pushing  it  forward 
into  the  wound.  A  tumour  may  now  be  removed,  an  ulcer 
excised,  a  bleeding-point  ligatured  or  cauterized,  the  pylorus 
exposed  and  divulsed,  the  oesophageal  opening  exposed  and 
dilated,  or  other  treatment  may  be  carried  out. 

In  the  case  of  foreign  bodies  in  the  stomach,  there  is,  of 
course,  no  need  to  make  the  omental  wound ;  but  an  an- 
terior incision  may  at  once  be  made,  and  the  object  or 
objects  seized  and  removed.  The  incision  in  the  stomach 
can  be  rapidly  closed  by  a  continuous  catgut  suture  for  the 
mucous  membrane  and  a  continuous  silk  suture  for  the 
serous  edges,  a  few  Lembert's  sutures  of  silk  sometimes 
being  applied  over  all  for  greater  security.  The  exposed 
parts  may  then  be  gently  sponged,  the  pads  or  sponges 
removed,  and  the  abdominal  wound  closed  without  drainage. 
Beyond  teaspoonfuls  of  water  for  the  first  twenty-four  to 
forty-eight  hours,  all  feeding  is  best  done  by  enemata :  but 
after  forty-eight  hours  the  amount  of  liquid  foods  may  be 
increased.  Later,  pultaceous  food  may  be  given,  but  it  is 
better  not  to  give  solid  food  for  a  week,  after  which  the 
treatment  should  be  as  in  any  other  abdominal  case. 

Dr.  Keen  {Philadelphia  Medical  Journal,  May  7,  i8g.8) 
insists  on  the  necessity  in  this,  as  in  all  similar  operations 
on  the  stomach,  of  washing  out  the  organ  before  it  is  opened, 
of  bringing  it  out  of  the  peritoneal  cavity,  and  of  protecting 
the  peritoneum  by  a  wall  of  iodoform  gauze.  Lavage  of 
the  stomach  is,  however,  undesirable  before  gastrotomy  for 


24  SURGERY  OF  THE  STOMACH 

foreign  bodies  and  for  haemorrhage,  and  is  unnecessary  as  a 
routine  prehminary  to  operation  ;  but  it  is  desirable,  if  prac- 
ticable, to  have  the  stomach  emptied  before  proceeding  to 
open  its  cavity. 

Gastrotomy  for  Foreign  Bodies. — The  removal  by  gastro- 
tomy  of  foreign  bodies  lodged  in  the  stomach  has  been 
attended  with  considerable  success.     A  preliminary  disten- 


FlG.    I. 


-FoREic.N  Bodies  successfully  Removed  from  the  Stomach  of 
A  Girl,  aged  Twelve.     (Mayo  Robson.) 

For  detailed  report,  see  Lancet,  November,  1894. 


sion  of  the  stomach  with  fluid  or  air  is  neither  advantageous 
nor  desirable.  The  indications  for  operation  are  the  presence 
of  a  foreign  body  which  can  neither  be  safely  dissolved  nor 
allowed  to  pass  through  the  gut,  and  which  is  actually  pro- 
ducing, or  is  likely  to  produce,  serious  symptoms.  One  of 
us  (Mayo  Robson)  has  described  a  case  {Lancet,  November  3, 
1894,  P-  1028)  in  which  'forty-two  cast-iron  garden  nails 
if  inches  long,  ninety-three  brass  and  tin  tacks  from  \  inch 
to    I    inch   long,    twelve    large    nails    (some    brass-headed), 


GASTROTOMY 


25 


three  collar-studs,  one  safety-pin,  and  one  sewing  needle,' 
were  removed  by  gastrotomy,  the  patient,  a  girl,  twelve 
years  of  age,  making  a  complete  recovery  and  being  now  in 
good  health.  The  photograph  here  reproduced  from  the 
College  of  Surgeons'  Museum  shows  the  objects  removed. 
The  value  of  transfusion  of  saline  fluid  in  the  treatment  of 
shock  was  well  shown  in  this  case.  Although  practically  no 
blood  was  lost  and  the  opera- 


tion was  not  very  prolonged, 
the  patient,  who  had  been 
much  exhausted  from  ex- 
cessive vomiting  before  the 
operation,  was  pulseless  after 
its  termination,  yet  trans- 
fusion restored  the  pulse  and 
rendered  recovery  possible. 

Dr.  A.  G.  Bernays  de- 
scribed a  case  in  which, 
through  an  incision  5  inches 
long  in  the  linea  alba,  he 
successfully  removed  a  table 
knife  from  the  stomach  of  a 
man  who  had  swallowed  it 
within  an  hour  previousl3\ 
The  patient  was  fed  by  the 
rectum  only  for  four  days, 
but  after  that  time  food  was 
given  by  the  mouth. 

Professor  Loreta  mentions 
the  case  of  a  woman  who,  having  swallowed  needles  with 
suicidal  intent,  suffered  severe  pain.  On  gastrotomy  being 
performed,  several  needles  were  removed  from  the  stomach 
and  others  were  drawn  out  of  the  left  lobe  of  the  liver. 
The  patient  recovered  without  a  bad  symptom,  and  was 
entirely  freed  from  her  suffering. 

Among  the  foreign  bodies  removed  by  gastrotomy  are 
masses  of  hair  forming  a  dense  ball.  The  most  remarkable 
specimen  of  this  kind  was  successfully  removed  by  Mr.  Paul 
Swain.     It  weighed  5  pounds  3  ounces.     It  can  be  Seen  in 


Fig.  2. — Bent  Pins  Removed  from 
Specimen  2379  (Fig.  5). 


26 


SURGERY  OF  THE  STOMACH 


the  Museum  of  the  Royal  College  of  Surgeons  of  England. 
A  photograph  here  reproduced  of  the  mass  of  hair  is  taken 
from  the  specimen  in  the  museum.  Schoff  (Wiener  Medi- 
cinhchc  Wochcnschrift,  November  i6,  1899)  has  collected 
sixteen  cases  of  hair-ball  in  the  human  stomach,  of  which 
eight  were  removed  by  operation,  all  successfully.  Statistics 
show  the  mortality  in  gastrotomy  for  foreign  bodies  to  be 


Fig.  3. — Pins  Removed  from  Specimen"  2379  (Fig.  5). 

15  per  cent,  in  a  series  of  seventy-nine  cases;  but  the  later 
cases  show  a  smaller  rate,  and  with  the  improved  technique 
of  to-day  it  will  doubtless  diminish  considerably.  Crede 
[Archiv.  fiir  Klinische  Chirurgie,  1886),  and  Ericker  {Deutsche 
Med.  Wochenschrift,  1897)  have  collected  fifty-four  cases, 
with  ten  deaths  ;  Heydenreich  (La  Semaine  Medicale,  1891) 
has  collected  thirteen  cases,  with  two  deaths  ;   Schoff  iWien. 


GASTROTOMY 


27 


Med.  WochenscJmft,  November,  1899)  has  collected  eight 
cases,  with  no  death ;  and  Mayo  Robson  {Lancet,  Decem- 
ber 23,  1899)  collected  four  cases  without  a  death. 

The  following  case,  though  not  actually  a  gastrotomy,  is  of 
interest  from  a  historical  point  of  view,  and  it  seems  to  be 
convenient  to  place  the  account  here  while  discussing  the 
operation  for  removal  of  foreign  bodies  from  the  stomach. 
The  account  is  taken  from  the  British  Medical  Journal,  1901. 

'  It  may  be  remembered  by  those  among  us  whose  professional 
memory  can  carry  them  back  a  quarter  of  a  century,  that  in  the 


Fig.  4. — A  Roll  of  Black   Human   Hair,  12   inches  long.   Weighing 

5  LBS.  3  oz  ,  Removed  successfully  from  a  Girl  of  Twenty. 
Lancet,  1895,  vol.  i.,  p.  1581.     (No.  2,381,  Royal  College  of  Surgeons' Museum. ) 

mid  seventies  there  was  much  talk  in  the  newspapers  of  a  French- 
man who  had  swallowed  a  fork.  The  fork  was  successfully 
removed  by  M.  Labbe,  surgeon  to  the  Charite,  now  a  member  of 
the  French  Senate,  and  the  case  is  quoted  in  the  books  as  mark- 
ing a  step  in  the  development  of  the  surgery  of  the  stomach.  The 
man,  whose  name  was  Lausseur,  lately  died,  twenty-five  years 
after  the  operation.  He  was  an  assistant  in  the  Magasins  du 
Printemps,  a  large  drapery  establishment,  and  he  was  in  the 
habit  of  amusing  his  fellow-employes  by  putting  into  his  mouth 
down  to  the  handle  the  big  scissors — 30  centimetres  long — with 
which  he  cut  samples.     One  day  at  luncheon  in  the  early  part  of 


28 


SURGERY  OF  THE  STOMACH 


1875,  by  way  of  what  our  ancestors  would  have  called  a  "  merrie 
and  conceited  jest,"  he  introduced  a  fork  into  his  mouth  with  the 
handle  downwards,  holding  the  points  between  his  teeth,  and 
closing  his  lips  so  as  to  hide  the  fork.  On  opening  his  mouth  to 
take  it  out  again  he  drew  in  his  breath,  and  the  fork  slipped  down 


Y\Q.  5.— Photograph  of  Stomach  from  a  Married  Woman,  aged 
Forty-one,  who  had  suffered  from  H.-ematemesis  at  Seventeen 

AND    several    times    LATER. 

Ultimately,  three  weeks'  incessant  vomiting  led  to  death.  A  post-mortem 
examination  showed  the  pylorus  behind  the  jiubes,  the  duodenum  being  dis- 
tended by  a  mass  of  pins  weighing  nearly  a  pound  and  causing  obstruction. 
There  were  no  peritoneal  adhesions.  (No.  2,379  Royal  College  of  Surgeons' 
Museum.) 


into  the  gullet.  Attempts  to  seize  it  with  forceps  failed,  and  it 
finally  found  its  way  into  the  stomach.  The  affair  for  some  weeks 
figured  prominently  in  the  newspapers.  "  L'homme  a  la  four- 
chette  "  was  the  sensation  of  the  day,  and  he  must  have  been  a 
good  advertisement  for  the  Magasins  du  Printemps,  for  people 


GASTROTOMY 


29 


wrote  there  from  Russia,  from  America,  and  nearly  every  part  of 
the  world,  asking  for  particulars  of  the  accident  and  as  to  the 
condition  of  the  patient.  Lausseur,  who  was  a  man  of  cheerful 
disposition,  did  not  allow  himself  to  be  depressed  by  the  know- 
ledge of  the  formidable  foreign  body  which  he  had  in  his  stomach. 
He  actually  composed  a  waltz  about  it,  which  he  called  "  La 
Fourchette,"  and  he  used  to  sing  it,  accompanying  himself  on  the 
piano.  He  did  not,  as  a  matter  of  fact,  suffer  so  much  incon- 
venience as  might  have  been  expected,  and  it  was  only  when  the 
fork  got  into  an  awkward  position  in  the  stomach  that  acute  pain 
was  caused.  After  a  time,  however,  an  abscess  formed,  which 
pointed  under  the  umbilicus,  and  symptoms  of  constitutional 
disturbance  showed  themselves.  M.  Labbe  opened  the  abscess 
and  removed  the  fork,  which  he  found  projecting  into  the  abscess 
cavity,  the  stomach  being  adherent  to  the  abdominal  wall.  This 
was  the  first  instance  in  which  a  foreign  body  was  removed  from 
the  stomach  by  a  surgical  procedure,  though  it  was  not,  strictly 
speaking,  a  gastrotomy.' 

The  following  case,  recorded  in  the  British  Medical  Journal, 
November  17,  igoo,  p.  1423,  by  Mr.  Walter  Spencer,  is  worth 
relating  here  : 

'  A  married  woman,  aged  forty-eight,  was  transferred  to  me  by 
Dr.  Murrell  with  the  following  history  :  She  had  been  in  very 
good  health  until  ten  months  ago,  when  suddenly  one  day,  whilst 
walking  in  the  street,  she  was  seized  with  a  violent  pain  in  the 
epigastrium,  which  made  her  feel  as  though  she  was  going  to 
burst.  The  abdomen  swelled  up,  but  she  did  not  pass  flatus ;  for 
seven  weeks  she  was  in  bed  on  a  fluid  diet,  with  poultices  on  the 
abdomen.  Then  she  got  up  and  tried  to  take  ordinary  food, 
but  it  caused  a  choking  sensation,  with  an  aching  pain  in  the 
epigastrium.  On  several  occasions  the  attacks  of  pain  seized  her 
as  at  the  first,  with  swelling  of  the  abdomen,  constipation,  and 
scantiness  of  urine.  A  fixed  lump  appeared  in  the  epigastrium, 
and  the  pain  became  worse  whilst  moving  about,  and  caused  her 
to  suff'er  from  dyspnoea. 

'  In  the  medical  ward  the  patient  could  only  take  fluids,  and  did 
not  improve.  It  was  decided,  therefore,  to  explore  the  painful 
lump  in  the  epigastrium,  and  the  case  is  an  admirable  instance  of 
the  value  of  surgical  exploration  in  obscure  and  stationary  cases. 
The  pyloric  third  of  the  stomach  was  found  adherent  to  the  back 
of  the  abdominal  wall,  being  pinned  there  by  a  fishbone  2^  inches 
in  length  and  of  the  size  of  a  stout  needle.  One  end  was  fixed  in 
the  left  rectus  muscle,  and  the  other  end  of  the  fishbone  projected 


30  SURGERY  OF  THE  STOMACH 

into  the  pyloric  third  of  the  cavity  of  the  stomach,  the  middle  of 
the  bone  being  surrounded  by  a  small  thick-walled  abscess  cavity. 
The  fishbone,  after  being  swallowed,  having  arrived  at  the  pylorus, 
instead  of  passing  through  end  on,  had  become  wedged  athwart 
the  orifice,  and  subsequently,  by  the  peristaltic  movements  of  the 
stomach,  one  end  had  been  driven  through  the  stomach  into  the 
abdominal  wall.  This  accounts  for  the  sudden  attack,  the 
immediate  result  of  which  was  a  reflex  inhibition  of  intestinal 
peristalsis,  causing  the  abdomen  to  become  swollen  by  tympanites, 
and  inducing  constipation  and  scanty  flow  of  urine.  At  the  same 
time  there  was  partial  obstruction  to  the  escape  of  food  from  the 
stomach,  hence  the  subsequent  difficulties  in  digestion.  The 
patient  could  never  recall  having  swallowed  the  bone.  The  fish- 
bone was  extracted,  and  the  adhesions  of  the  stomach  to  the 
abdominal  wall  divided.  The  portion  of  the  anterior  wall  of  the 
stomach,  which  had  formed  a  thickened  mass  about  i|  inches  in 
diameter  around  the  bone,  was  excised ;  then  the  gap  was  closed 
by  a  double  row  of  sero-muscular  sutures.  The  abdominal  wound 
healed  at  once,  a  sinus  leading  down  to  the  abscess  cavity  closed 
after  a  short  delay,  and  she  was  seen  some  time,  after  her  discharge 
from  the  hospital  in  good  health.' 

The  effect  produced  on  the  stomach  by  various  foreign 
bodies  accidentally  or  intentionally  swallowed  can  be  studied 
in  a  series  of  specimens  in  the  Hunterian  Museum  at  the 
Ro3'al  College  of  Surgeons.  Photographs  of  several  of  the 
specimens  are  here  reproduced. 

No.  2,377  (Royal  College  of  Surgeons)  shows  the  remains 
of  a  knife  swallowed  two  months  before  death.  No.  2,378 
(Royal  College  of  Surgeons)  shows  the  blades  and  iron 
portions  of  three  or  more  clasp-knives  swallowed  by  a  man 
and  voided  per  anuni ;  the  man  recovered.  No.  2,379  (Royal 
College  of  Surgeons)  shows  the  stomach  from  a  woman,  aged 
forty-one  years,  who  had  suffered  from  h^ematemesis  at 
seventeen  years  of  age  and  several  times  later ;  ultimately 
incessant  vomiting  led  to  death.  A  post-mortem  examina- 
tion showed  the  pylorus  behind  the  pubes,  and  the  duodenum 
distended  by  a  mass  of  pins  weighing  nearly  a  pound,  which 
had  caused  the  obstruction.  The  bent  pins  removed  from 
the  last  specimen  are  shown  in  No.  2,380  (Royal  College  of 
Surgeons).  No.  2,381a  (Royal  College  of  Surgeons)  shows 
a  roll  of  black   human   hair,  12   inches   long  and  weighing 


GASTROTOMY  31 

5  pounds  3  ounces,  removed  from  a  girl,  twenty  years  of  age, 
by  Mr.  Paul  Swain  ;  the  patient  recovered. 

Gastrotomy  may  be  performed  for  the  removal  of  foreign  bodies 
impacted  in  the  lower  end  of  the  oesophagus  when  all  attempts 
to  remove  them  by  the  mouth  or  to  push  them  on  by  bougies 
have  failed. 

When  a  foreign  body,  except  in  the  case  of  a  coin,  is  im- 
pacted in  the  lower  part  of  the  oesophagus,  and  cannot  be 
removed  by  ordinary  means,  the  surgeon  may  pursue  one  of 
three  courses  : 

{a)  (Esophagotomy  in  the  neck,  which  is  not  to  be  re- 
commended. 

(6)  Intra-mediastinal  oesophagotomy,  an  extremely  difficult 
and  dangerous  operation,  which  has,  we  believe,  never  been 
done  successfully. 

(c)  Gastrotomy,  the  operation  we  would  recommend  as 
being  safer  and  more  efficient  than  any  other. 

In  the  case  of  impacted  coins,  our  experience  is  that  by 
the  use  of  the  instrument  known  as  a  coin-catcher,  which  we 
believe  was  invented  by  the  late  William  Hey,  of  Leeds, 
they  can  always  be  safely  removed. 

One  of  us  (Mayo  Robson)  recently  published  two  cases  of 
this  kind  in  children  where,  after  the  coins  had  been  localized 
by  skiagraphy,  they  were  removed  by  means  of  the  coin- 
catcher  with  the  greatest  facility,  although  they  had  been 
impacted  for  four  months  {British  Medical  Journal,  vol.  i.. 
1898). 

At  the  American  International  Medical  Congress  Dr. 
Maurice  H.  Richardson  {Boston  Medical  Journal,  Decem- 
ber 16,  1886)  read  a  paper  on  the  possibility  of  operation  on 
the  oesophagus  through  the  stomach.  He  had  verified  his 
statements  by  experiments  on  sixty  bodies,  and  had  in  one 
case  operated  successfully  on  a  man,  thirty-seven  years  of 
age,  who  had  eleven  months  previously  swallowed  a  denture 
of  four  teeth,  which  had  become  impacted  at  the  lower  end 
of  the  oesophagus.  The  patient  had  lost  fifty  pounds  in 
weight,  and  it  was  found  to  be  quite  impossible  to  extricate 
the  plate  by  means  of  forceps  introduced  through  the  mouth. 
After  the  stomach  had  been  opened,  the  hand  was  inserted ; 


32  SURGERY  OF  THE  STOMACH 

on  reaching  the  cardiac  orifice,  the  finger  discovered  the 
plate  about  2  inches  above  the  diaphragm.  B}-  means  of 
digital  manipulation  it  was  detached  and  withdrawn  ;  the 
stomach  was  then  carefully  sutured,  and  the  abdomen  closed. 
The  patient  rapidly  gained  weight,  and  was  soon  able  to 
resume  his  work.  The  conclusions  Dr.  Richardson  drew 
from  his  experiments  were :  that  the  oblique  incision  below 
the  margin  of  the  ribs  is  the  best  ;  that  the  stomach,  after 
being  withdrawn  from  the  abdomen  a  little,  should  be  opened 
to  the  right  of  the  convexity  of  the  lesser  curve  ;  that  the 
assistant  should,  by  traction  on  the  stomach,  put  the  lesser 
curve  on  the  stretch  ;  and  that  the  sulcus  so  formed  is  always 
a  certain  guide  to  the  cardiac  orifice.  When  a  foreign  body 
is  impacted  at  the  lowest  part  of  the  oesophagus,  it  is  about 
6  inches  below  the  opening  made  in  oesophagotomy  ;  and  if 
it  be  firmlv  impacted  and  require  much  force  to  detach  it, 
the  safer  plan  will  probably  be  to  perform  gastrotomy,  and 
draw  it  down  a  little  way,  than  to  perform  oesophagotomy, 
and  draw  it  forcibly  a  distance  of  6  inches  past  very  impor- 
tant structures. 

Dr.  Bull,  of  New  York,  has  recorded  {Ntw  York  Medical 
Journal,  October  29,  1897)  an  operation  in  which  he  success- 
fully detached  an  impacted  peach-stone  from  the  lower  end 
of  the  oesophagus  in  a  thin  boy,  aged  sixteen  years,  and  then, 
by  attaching  a  piece  of  string  to  a  sponge,  and  dragging  the 
sponge  upwards  from  the  gastrotom}-  opening  to  the  mouth, 
he  was  able  to  bring  the  stone  with  it. 

In  the  Lancet  for  February  23,  1901,  is  an  account  of  a 
case  by  Mr.  Flavell  Edmunds,  where  gastrotomy  was  suc- 
cessfully employed  in  a  man,  aged  fort3'-five,  for  a  tooth- 
plate  impacted  in  the  lower  end  of  the  oesophagus. 

Gastrotomy  as  a  preliminary  to  forcible  dilatation  of  the  pyloric 
or  cardiac  orifice  of  the  stomach  was  suggested  by  Richter,  and 
carried  out  b}-  Loreta  in  September,  1882. 

In  stenosis  of  the  pylorus,  however,  divulsion  has,  speaking 
generally,  given  way  to  pyloroplasty  or  gastro-enterostomy, 
for  the  double  reason  that  pylorodiosis  has  a  greater  death- 
rate,  and  is  more  liable  to  be  followed  by  relapses.  It  may 
nevertheless  be  advisable  in  those  cases  due  to  spasm  and 


GASTROTOMY  33 

hypertrophy  of  the  pyloric  sphincter.  In  a  certain  number 
of  these  cases,  however,  the  sphincter  may  be  divulsed  with- 
out gastrotomy  by  invaginating  the  stomach  wall,  and  gradu- 
ally pushing  the  finger  through  the  pyloric  opening,  as 
suggested  by  Hahn.  This  subject  will  be  considered  more 
in  detail  under  simple  dilatation  of  the  stomach. 

In  simple  cicatricial  stricture  of  the  oesophagus  at  or  near  the 
cardiac  orifice,  if  dilatation  by  bougies  is  impossible  or  has 
failed  to  keep  the  stricture  open,  the  operation  of  gastrotomy 
may  be  performed,  and  an  attempt  made  to  dilate  the  orifice 
from  below.  This  operation  has  proved  very  successful. 
Gissler  {Beitrdgefur  Klin.  Chiriirgie,  Tubingen,  1892,  vol.  viii., 
p.  log)  has  collected  ten  cases,  and  Kendal  Franks  twenty- 
one  cases,  all  the  patients  recovering.  The  operation  may 
be  performed  in  two  stages,  in  which  case  a  large  gastrotomy 
opening  must  be  made  and  the  dilatation  proceeded  with 
later.  The  one-stage  operation  is  to  be  preferred,  as  the 
finger  can  then  palpate  the  cardiac  orifice,  and  a  mechanical 
dilator  may  be  used  if  necessary.  For  subsequent  operation 
a  gastric  fistula  may  be  left,  if  it  be  thought  that  there  will 
be  difficulty  in  keeping  the  passage  patent  by  bougies  intro- 
duced through  the  mouth.  The  dilator  that  Loreta  employed 
was  after  the  pattern  of  Dupuytren's  lithotomy  dilator,  only 
longer,  and  incapable  of  dilating  beyond  5  centimetres. 
Kendal  Franks  used  Otis's  urethrotome,  from  which  he  had 
previously  removed  the  knife.  Weiss's  rectal  dilator  may  be 
conveniently  employed.  x\bbe  has  recently  devised  a  method 
of  dividmg  a  simple  stricture  of  the  lower  end  of  the 
oesophagus,  or  of  the  cardiac  orifice  of  the  stomach,  by 
passing  a  string  through  the  stricture  from  below  until  it 
emerges  at  the  mouth  ;  then,  by  putting  the  string  on  the 
stretch,  and  running  it  rapidly  upwards  and  downwards,  the 
stricture  is  soon  divided.  The  stomach  and  the  abdominal 
opening  are  then  closed,  and  the  stricture  is  kept  permeable 
by  the  regular  passage  of  bougies.  The  diagnosis  is  of  the 
first  importance,  as  in  malignant  disease  the  operation  will 
be  useless  and  may  be  very  dangerous.  In  simple  stricture 
of  the  cardiac  orifice  there  will  probabh'  be  a  history  of 
corrosive  fluid  having  been  swallowed  some  time  previously, 

3 


34  SURGERY  OF  THE  STOMACH 

and  the  symptoms  will  also  be  of  longer  duration  than  if  the 
stricture  be  malignant. 

Gastrotomy  for  the  removal  of  a  polypus  or  other  growth 
projecting  into  the  cavity  of  the  stomach  or  occluding  the 
pylorus  is  an  operation  seldom  required,  since  simple  tumours 
of  the  stomach  are  uncommon.  The  following  is  a  good 
example  :  A  middle-aged  man,  with  a  history  of  long-con- 
tinued dyspepsia  and  of  loss  of  flesh,  came  under  the  care  of 
one  of  us — Mayo  Robson — for  dilatation  of  the  stomach, 
which  was  producing  the  usual  symptoms  with  great  loss  of 
flesh.  The  pylorus  appeared  to  be  thickened,  and  on  opening 
the  stomach  the  lumen  of  the  pylorus  was  seen  to  be  occu- 
pied by  a  polypoid  projection  with  a  wide  base,  so  that  the 
passage  of  the  stomach  contents  onward  was  almost  com- 
pletely prevented.  The  removal  of  the  growth  by  scissors, 
and  the  suture  of  the  longitudinal  wound  transversely,  led  to 
such  relief  that  the  patient  gained  weight  at  first  at  the  rate 
of  half  a  pound  a  day,  and  in  three  months  he  weighed 
between  two  and  three  stones  more  than  before  the  operation. 
The  growth  proved  to  be  an  adenoma. 

Chaput  (Bulletin  et  Memoire  de  la  Societe  de  Chinirgie,  1894) 
records  a  case  in  which  he  excised  a  pedunculated  adenoma 
from  the  posterior  wall  of  the  stomach;  and  C.  B.  Lyman 
{Annals  of  Surgery)  reports  a  case  of  removal  of  a  pedun- 
culated carcinoma  of  the  stomach  through  a  gastrotomy 
opening.  Mr.  Bennett  {British  Medical  Jotmial,  February  3, 
igoo)  has  reported  an  interesting  case  of  the  kind,  where  the 
removal  of  a  simple  papilloma  that  occluded  the  pylorus  from 
time  to  time,  and  led  to  intermittent  dilatation  of  the  stomach, 
cured  the  patient,  a  man  aged  thirty-five  years,  who  had  been 
ill  for  years. 

Gastrotomy  for  exploration  in  cases  of  intractable  gastric  ulcer 
not  yielding  to  ordinary  treatment,  and  for  gastrorrhagia, 
will  be  considered  more  conveniently  when  we  come  to 
discuss  ulcer  of  the  stomach. 

Gastrotomy  for  partial  removal  of  cancerous  growths  in  the 
stomach  by  the  curette  is  an  operation  that  has  been  per- 
formed by  Dr.  Bernays,  of  St.  Louis.  He  has  recorded 
{Annals  of  Surgery,  December,  1887)  some  cases  in  which 


GASTROTOMY  35 

he  had  given  rehef  by  this  method  ;  but  in  view  of  the  better 
results  from  gastrectomy  or  gastro-enterostomy,  it  is  scarcely 
Hkely  that  this  operation  will  continue  to  hold  a  place  in 
surgery,  both  from  its  uncertainty  and  from  the  danger  of 
haemorrhage  and  perforation  ;  moreover,  the  relief  given  by 
such  an  operation  can  only  be  of  a  very  temporary  nature. 


3—2 


CHAPTER  II 

CONGENITAL  STENOSIS  OF  THE  PYLORUS 

Considerable  attention  has  within  the  last  few  years  been 
given  to  this  condition,  which  has  been  variously  described 
as  '  congenital  stricture,'  '  congenital  hypertrophy '  of  the 
pylorus,  and  'congenital  gastric  spasm,' 

The  first  recorded  case  is  that  given  by  Williamson 
{London  and  Edinburgh  Monthly  Jonrnal  of  Medical  Science, 
1841,  p.  23)  ;  the  second  that  by  Davoski  {Caspar's 
Wochenschr.,  1842,  No.  7).  These  two  cases,  however,  sank 
out  of  remembrance,  and  were  only  recalled  after  the  de- 
scription of  a  case  in  1888  by  Hirschsprung  of  Copenhagen 
{Jahrb.  f.  Kindcrheil.,  vol.  xxviii.).  Since  then  over  forty 
examples  have  been  met  with. 

Sjrmptoms. 

The  symptoms  may  appear  immediately  after  birth,  or 
more  frequently  after  an  interval  of  a  few  days  or  weeks. 
The  chief  of  them  is  vomiting,  coming  on  without  apparent 
reason  immediately,  or  very  shortly,  after  the  administra- 
tion of  food,  accompanied  by  restlessness  or  convulsions, 
and  increasing  gradually  in  frequency  until  it  becomes  per- 
sistent. Though  this  is  the  rule,  it  is  not  invariable ;  for, 
as  the  stomach  slowly  distends,  the  vomiting  may  become 
less  frequent  and  in  larger  quantity.  Temporary  relief 
has  been  noticed  after  washing  out  the  stomach  through 
a  Nelaton  catheter,  and  the  regular  administration  of  very 
small  quantities  of  fluid.  It  has  been  especially  emphasized 
in  many  cases  that  the  vomit  contains  no  bile.  More  or  less 
swiftly — in  proportion,  probably,  to  the  degree  of  stenosis — 


CONGENITAL  STENOSIS  OF  THE  PYLORUS  37 

the  stomach  expands,  and  eventually  may  occupy  the 
greater  part  of  the  abdomen.  The  child  wastes  rapidly, 
and  the  intestines,  through  lack  of  food,  become  collapsed 
and  empty.  The  contrast,  then,  between  the  upper  half  of 
the  abdomen,  containing  the  distended  stomach,  and  the 
lower  half,  in  which  lie  only  shrunken  coils  of  intestine,  is 
striking  and  remarkable.  Constipation  is,  of  course,  present, 
as  the  bowel  has  no  contents  of  which  to  relieve  itself. 
When  empty,  the  stomach  may  be  felt  as  a  hard,  rounded 
swelling  in  the  epigastrium. 

A  pyloric  tumour  has  been  palpable  in  a  few  cases.  When 
the  stomach  is  distended  with  food  or  air,  waves  of  contrac- 
tion may  be  seen  passing  across  it.  Emaciation  is  pro- 
gressive and  extreme,  and  the  little  infant,  constantly 
vomiting,  dies  of  starvation  and  exhaustion.  Such  is  the 
clinical  picture  of  an  acute  case. 

There  are,  however,  on  record  certain  cases  which  have 
been  diagnosed  as  congenital  stenosis,  but  which  have 
recovered.  Still  suggests  that  these  are  instances  of  develop- 
mental variations  in  the  amount  of  muscular  tissue  in  the 
pylorus  in  which  the  stenosis  is  not  great.  It  is  more  than 
probable  that  slighter  degrees  of  the  same  disease,  not 
proving  fatal  in  infancy,  may  come  under  observation  later, 
as  examples  of  pyloric  stenosis ;  for,  as  Rolleston  says,  '  it  is 
conceivable  that  a  primary  muscular  excess  might  in  course 
of  time  undergo  a  fibrous  transformation,  and  result  in 
fibrous  stricture  of  the  pylorus.' 

The  following  interesting  case,  reported  by  Dr.  Coates 
{Lancet,  December  8,  igoo,  p.  1645),  is  worth  giving  in 
extenso.  Recovery  seemed  to  be  due  to  systematic  washing 
out  and  cleansing  of  the  stomach.  Probably  stenosis  of  the 
pylorus,  spasmodic  or  structural,  was  the  cause  of  the  dilata- 
tion. 

A  girl  was  born  on  January  24,  1900,  and  weighed  7  pounds 
13  ounces.  She  seemed  quite  healthy,  and  apparently  remained 
so  for  nearly  three  weeks.  Her  mother  was  unable  to  nurse  her. 
She  was  fed  on  humanized  milk.  On  February  14  she  began  to 
be  frequently  sick.  From  the  17th  to  the  19th  the  vomiting 
suddenly  changed  in  character  ;  she  was  sick  only  once  in  twenty- 


38.  SURGERY  OF  THE  STOMACH 

four  hours  ;  then  a  very  large  quantity,  at  least  a  pint,  came  away. 
At  the  same  time  micturition  became  scanty,  and  the  motions 
consisted  of  only  small  quantities  of  mucus  stained  almost  black 
with  altered  bile.  The  stomach  was  manifestly  much  dilated, 
whilst,  from  the  absence  of  residue  of  food  in  the  bowels  and  the 
very  scanty  micturition,  it  was  evident  that  little  or  nothing 
passed  through  the  pylorus ;  but  whether  there  was  stenosis,  or 
whether  the  enormous  dilatation  of  the  stomach  had  produced  a 
kink  that  nothing  could  pass,  was  not  evident.  The  treatment 
consisted  in  feeding  her  at  intervals  of  two  to  three  hours  with 
small,  measured  quantities  of  food.  One  teaspoonful  of  the 
following  mixture  was  given  after  each  meal,  to  aid  the  digestion 
and  prevent  fermentation  in  the  dilated  stomach :  Acidi  hydrochlori 
dil.,  25  minims;  glycerini  pepsini  acidi,  i^  drachms;  acid- 
carbolici,  ^  grain ;  aq.  ad  i^  ounces.  On  the  28th,  as  she 
was  slowly  but  steadily  losing  ground,  nutritive  enemata  were 
given.  Each  enema  consisted  of  i  ounce  of  peptonized  human 
milk  with  2  drops  of  brandy.  The  enemata  were  given  every 
three  hours  until  the  end  of  May,  and,  with  the  exception  of  a 
few  days  when  there  was  some  diarrhoea,  they  were  always 
retained  and  absorbed.  The  bowel  was  washed  out  once  a  day 
with  soap  and  water.  Early  in  March  she  had  severe  gastro- 
intestinal catarrh,  with  sickness  and  diarrhoea.  The  vomit 
contained  greenish-yellow  muco-pus  mixed  with  curds.  The 
stools  were  frequent  and  foul-smelling.  She  had  fever,  the 
temperature  varying  from  go°  in  the  morning  to  102°  at  night, 
and  a  loud  endocardial  mitral  regurgitant  murmur  was  developed. 
She  lost  flesh  very  rapidly,  her  weight  on  March  17  being  5  pounds 
13  ounces,  a  loss  of  2  pounds  since  birth.  Her  condition  looked 
perfectly  hopeless.  She  was  extremely  emaciated,  and  had  a 
shrivelled,  dry  skin  and  distended  abdomen.  The  abdominal 
wall  was  so  thin  that  the  liver  could  be  recognised  from  the 
dark  colour  showing  through.  The  dilated  stomach  could  also 
be  easily  made  out,  and  slowly-moving  peristaltic  waves  were 
seen  passing  over  it  from  time  to  time.  For  a  few  days  milk 
was  entirely  stopped  by  the  mouth,  and  she  was  put  on  raw 
meat,  meat  juice,  and  warm  water  as  food,  and  sulpho-carbolate 
of  soda  and  carbonate  of  bismuth  as  medicine.  A  few  days  later, 
as  her  temperature  never  rose  above  99°  and  the  diarrhoea  had 
stopped,  human  milk  was  given  as  well.  On  March  19  she  had 
still  lost  weight,  being  now  5  pounds  11  ounces  at  seven  weeks 
from  birth,  when  she  ought  to  have  weighed  over  10  pounds. 

From  the  constant  loss  of  weight  and  general  condition,  it  was 
obvious  that  she  would  die  unless  the  state  of  her  stomach  could 
be  improved,  and  as  a  last  resource  it  was  determined  to  wash  it 


CONGENITAL  STENOSIS  OF  THE  PYLORUS  39 

out  with  a  solution  of  sodium  bicarbonate,  25  grains  ;  sodium 
sulpho  -  carbolate,  15  grains;  euthymol,  \  drachm;  aq.  ad 
i\  ounces.  On  IMarch  22  a  No.  12  soft  elastic  catheter,  india- 
rubber  tube,  and  glass  funnel  were  used.  The  catheter  was 
passed  through  the  mouth  every  morning  about  three  hours 
after  a  meal.  When  the  catheter  entered  the  stomach,  gas 
generally  escaped,  and  then  from  3  to  4  ounces  of  thick  slime 
and  curdled  milk  were  evacuated.  The  stomach  was  then 
washed  out,  and  the  resultant  fluids  w^ere  measured.  Imme- 
diately after  the  stomach  was  cleansed,  a  teaspoonful  of  the 
following  mixture  was  given  :  Spiritus  aetheris  chlorici,  15  minims; 
bismuth  carbonate,  40  grains  ;  sodium  bicarbonate,  12  grains  ; 
sodium  sulpho  -  carbolate,  \  drachm ;  decoctum  h^matoxyli, 
6  drachms  ;  aq.  cinnamon  ad  i  J  ounces  ;  and  a  quarter  of  an 
hour  later  she  was  fed  with  2  or  3  ounces  of  human  milk  freshly 
drawn  off.  She  was  fed  alternately  every  two  or  three  hours  with 
from  2  to  3  ounces  of  human  milk  and  i  ounce  of  meat -juice.  She 
was  not  put  to  the  breast,  so  that  there  should  be  no  opportunity 
of  overfilling  the  stomach.  From  this  time  improvement  was 
decided ;  she  spent  very  comfortable  days,  but  used  to  get 
rather  restless  by  evening,  and  was  decidedly  uncomfortable 
during  the  night.  The  day  after  the  washing  out  was  com- 
menced she  began  to  pass  much  more  urine  ;  three  days  later 
and  subsequently  she  had  almost  normal  motions.  At  the  end 
of  March  the  meat -juice  was  stopped,  and  she  was  put  regularly 
to  the  breast.  By  April  2  she  had  gained  2  ounces ;  by  the 
6th  she  had  gained  2  ounces  more.  As  the  nights  were  bad  and 
the  days  good,  lavage  was  performed  night  and  morning  about 
three  hours  after  a  meal.  Each  time  about  3  ounces  of  slime 
and  curd  were  removed.  By  May  i  she  had  gained  over  i  pound, 
her  weight  being  6  pounds  13  ounces.  She  made  uninterrupted 
progress,  so  that  by  the  12th  the  residue  of  slime  and  curd 
removed  was  reduced  to  between  \\  and  2  ounces.  After  the 
19th  lavage  was  performed  only  occasionally.  On  the  23rd, 
after  forty-eight  hours'  interval,  only  \\  ounces  of  residue  was 
found.  On  the  30th  her  weight  was  8  pounds  4  ounces  ;  on 
July  17  over  12  pounds.  Her  heart  was  now  perfectly  normal, 
the  murmur  having  disappeared  on  March  20. 

There  are  two  points  worth  noting  :  (i)  The  patient's  sensa- 
tions of  hunger  were  apparently  caused  by  the  absence  of  digestible 
food  in  the  stomach.  She  always  showed  signs  of  hunger  two  or 
three  hours  after  feeding,  even  though  her  stomach  contained 
3  or  4  ounces  of  slime  and  curd.  After  this  had  been  removed, 
the  stomach  cleansed,  and  2  or  3  ounces  of  milk  given,  she  would 
appear  to  be  satisfied  for  over  two  hours,  although  the'  stomach 


40  SURGERY  OF  THE  STOMACH 

really  contained  less  than  when  she  was  hungry.  Her  sensations 
of  repletion  depended  on  the  nutritive  value  rather  than  on  the 
quantity  of  the  matter  in  the  stomach.  (2)  Her  attack  of  severe 
febrile,  muco-purulent,  gastro- intestinal  catarrh  was  rapidly 
followed  by  the  appearance  of  a  loud  mitral  systolic  murmur 
which  resembled  one  due  to  rheumatic  endocarditis.  Soon  after 
the  stomach  was  brought  into  a  healthier  condition  and  the 
catarrh  and  fever  had  subsided,  the  murmur  disappeared. 

Cases  of  febrile  disturbance,  accompanied  by  gastro-intestinal 
trouble,  and  followed  by  excited  action  of  the  heart  and  the 
development  of  an  endocardial  murmur,  usually  at  the  mitral 
orifice,  are  common  in  children.  This  case  appears  to  show 
that  the  endocardial  infection  came  from  the  alimentary  canal. 
An  extremely  severe  attack  of  acute  dilatation  of  the  stomach 
was  thus  cured  by  systematic  lavage  twice  a  day.  After  a  few 
days  it  was  clear  that  the  food  given  was  better  digested,  and 
that  less  slime  was  secreted. 

A  degree  of  congenital  stenosis  is  doubtless  a  frequent, 
though  often  an  unrecognised,  cause  of  dilatation  of  the 
stomach  in  young  adults.  Maier  (Virch.  Archiv.,  Bd.  102) 
cites  a  number  of  cases,  mostly  in  adults,  of  chronic  catarrh 
of  the  gastric  mucous  membrane,  wdth  dilatation,  in  which 
stenosis  of  the  pylorus,  varying  from  3  millimetres  to 
I  centimetre  (the  normal  being  i  to  3  centimetres),  was 
found.  He  is  careful  to  distinguish  betv\'een  the  congenital 
form  and  that  due  to  catarrh,  ulcer,  and  cancer,  the  acquired 
forms  of  stenosis,  and  gives  his  reasons  for  considering  the 
stenosis  primary  and  the  catarrh  secondary  in  the  cases 
mentioned.  He  acknowledges,  however,  that  clinically  the 
distinction  is  extremely  difficult.  Basing  his  classification 
on  the  anatomical  structure  of  the  pylorus,  he  distinguishes 
between  a  simple  form  of  stenosis,  in  which  there  is  a  round 
or  slit-like  narrowing  of  the  pyloric  orifice,  and  a  complicated 
form,  due  to  a  hypertrophy  of  the  longitudinal  or  of  the 
circular  fibres  of  the  pyloric  region.  In  the  first  case,  where 
the  longitudinal  fibres  are  hypertrophied,  the  stenosis  is 
usually  conical  in  shape,  with  the  apex  of  the  cone  at  the 
pylorus,  and  projecting  into  the  duodenum  after  the  manner 
of  the  OS  uteri  into  the  vagina  ;  but  sometimes  it  is  ringlike, 
the  constriction  then  measuring  as  low  as  from  4  millimetres 
to   5   millimetres.     When  the   circular  fibres,   on    the  other 


CONGENITAL  STENOSIS  OF  THE  PYLORUS  41 

hand,  are  increased,  the  form  taken  is  usually  that  of  a  thick 
swelling,  the  lumen  of  the  canal  not  being  so  much  reduced 
as  in  the  former  case. 

This  form  of  stenosis  may  explain  many  of  the  cases  of 
dilatation  and  catarrh  of  the  stomach  coming  on  in  young 
adults  without  apparent  cause,  and  it  may  also  explain  many 
of  the  cases  of  persistent  vomiting  set  down  to  a  vicious 
habit,  or  to  hysteria.  To  judge  from  the  literature  of  the 
subject,  this  condition  is  not  of  frequent  occurrence ;  but  it 
may  be  more  common  than  is  supposed,  as  necropsies  are 
not  frequently  made  in  the  case  of  children  dying  out  of 
hospital,  and  persistent  vomiting  in  infants  is  not  a  very 
uncommon  event. 

The  transition  from  the  acute  cases,  speedily  ending  in 
death,  occurring  in  infants,  and  the  chronic  cases,  where 
symptoms  are  noticed  for  the  first  time  in  young  adults,  or 
where  symptoms  long  troublesome  in  a  slight  degree  become 
aggressive,  is  clearly  shown  by  the  following  series  of  cases : 

1.  Batten's  Case. — A  male  infant  eleven  weeks  old,  weighing 
7^  pounds.  Up  to  the  age  of  five  weeks  the  child  was  quite  well ; 
he  then  began  to  throw  up  his  food,  and  had  continued  to  vomit 
afterwards.  A  diagnosis  of  pyloric  hypertrophy  was  made  from 
the  following  points  :  (i)  A  healthy  baby  at  birth.  (2)  Vomit- 
^^S'  (3)  Constipation.  (4)  Subnormal  temperature  in  rectum. 
(5)  Wasting.  (6)  Marked  dilatation  and  peristalsis  of  stomach. 
(7)  A  tumour  in  the  position  of  the  pylorus.  (8)  i\bsence  of  the 
usual  signs  of  gastritis.  The  infant  was  fed  by  a  nasal  tube. 
Treatment  was  begun  in  December,  i8g8.  In  May,  1899,  the 
patient  weighed  16  pounds.  In  August  an  attack  of  acute  gastro- 
enteritis with  broncho-pneumonia  proved  fatal.  At  the  post- 
mortem a  hypertrophied  pylorus  and  stomach  were  found. 

2.  Kehr's  Case. — During  the  first  few  months  of  life  the  child 
had  developed  normally ;  then  it  began  to  vomit  every  time  it 
took  food,  and  to  lose  weight.  Stenosis  of  the  pylorus  with 
hypertrophy  was  found  at  the  time  a  gastro-enterostomy  was 
performed. 

3.  Sonnenburg's  Case. — In  which  gastro-enterostomy  was 
performed  in  a  child  of  five  years  of  age  for  congenital  stenosis. 

4.  Hunsy's  Case. — A  boy  aged  eleven,  who  had  suffered  from 
infancy  from  general  alimentary  disorder,  whose  principal 
symptoms  were  swelling  of  the  abdomen,  especially  in  the  left 


42  SURGERY  OF  THE  STOMACH 

loAver  region,  vomiting  of  large  quantities  of  half-digested  food, 
false  appetite,  constipation,  etc.  The  signs  were  splashing  or 
gurgling  in  the  swollen  region,  cyanosis,  and  undoubted  emacia- 
tion. On  distending  the  stomach  with  carbonic  acid  gas,  it  was 
found  to  be  enormously  enlarged,  extending  downwards  to  the 
symphysis  pubis.  On  opening  the  abdomen  a  '  concentric 
thickened  ring  of  hypertrophy  round  the  pylorus'  was  found, 
about  a  finger's  breadth  in  width,  without  any  cicatrix  or  other 
adhesions  that  would  raise  any  suspicions  of  preceding  inflamma- 
tion. Gastro-enterostomy  was  performed  with  good  results. 
Hunsy  adds  that  the  case  is  '  doubtless  one  of  congenital  muscular 
hypertrophy  of  the  pylorus.' 

5.  Mayo  Robson's  Case.— Mr.  A.  J.  H.,  aged  twenty-four  ;  had 
suffered  from  indigestion  which  had  been  present  for  five  years, 
and  which  had  had  a  gradual  and  painless  onset.  He  had 
discomfort  and  fulness  after  meals  with  flatulency,  evidently 
associated  with  fermentation  of  the  stomach  contents.  He  was 
5  feet  10  inches  in  height,  but  only  weighed  8  stones  10  pounds, 
and,  as  he  had  recently  further  lost  weight  and  strength,  his  friends 
were  naturally  anxious  about  him.  He  had  already  had  his 
stomach  washed  out  twice  a  week  for  some  time,  but  without 
benefit.  On  making  a  physical  examination  no  tumour  could  be 
felt ;  but  the  stomach  splash  was  easily  obtained,  and  on  distend- 
ing the  stomach  with  CO^  it  was  found  to  reach  three  fingers' 
breadth  below  the  umbilicus.  On  June  9  an  operation  was 
performed  on  him,  when  the  pylorus  was  found  to  be  con- 
tracted, so  that  the  little  finger  could  only  with  difficulty  be 
passed  through  it. 

Pylorodiosis  was  performed  by  Hahn's  method,  and  the  pyloric 
sphincter  was  stretched  until  it  readily  admitted  two  fingers  by 
invagination.  The  operation  was  performed  at  Huddersfield 
with  the  assistance  of  Dr.  Irving,  under  whose  care  he  remained. 
He  made  a  good  recovery,  and  gained  about  \  stone  in  weight  in 
the  course  of  the  next  few  weeks.  The  improvement  lasted  for 
three  months,  when  he  arrived  at  a  standstill  for  a  month,  and 
during  the  next  three  months  he  rapidly  lost  what  he  had  gained, 
and  his  weight  diminished  to  8  stones  7  pounds.  There  was  no 
vomiting,  and  he  had  no  pain,  but  the  fulness  and  flatulency  with 
acidity  continued.  We  saw  him  again  in  January  of  the  following 
year.  On  distending  the  stomach,  we  found  that  it  had  returned 
to  its  former  volume.  He  was  thin  from  illness  and  weak,  and 
in  spite  of  lavage  of  the  stomach,  careful  feeding,  and  rest  in  bed 
he  made  no  improvement,  and  it  became  clear  that  unless  some- 
thing could  be  done  he  w^ould  probably  die. 

A  posterior    gastro-enterostomy  was   therefore    performed    on 


CONGENITAL  STENOSIS  OF  THE  PYLORUS  43 

February  25,  1900.  It  v^-as  interesting  to  note  that  a  distinct 
scar  over  the  pylorus  could  now  be  seen,  as  if  the  pylorodiosis 
had  led  to  ulceration,  and  so  to  cicatricial  contraction.  He  is  now 
making  a  satisfactory  recovery  from  the  gastro-enterostomy. 

There  can  be  little  hesitation  in  affirming  that  a  congenital 
abnormality  in  the  pylorus  of  some,  at  present  indeterminate, 
character  may  after  the  lapse  of  few  or  many  years  be  so 
altered,  or  added  to,  as  to  cause  symptoms  of  pyloric  obstruc- 
tion. The  conditions  and  the  frequency  of  such  cases 
require  further  investigation. 

Pathology. 

In  some  cases  the  stomach  is  found  enormously  dilated ; 
in  others  there  is  a  moderate  degree  of  dilatation,  with 
hypertrophy.  In  all  the  pylorus  shows  a  funnel-shaped  cir- 
cular thickening.  This  has  varied  in  extent  from  \  an  inch 
to  2  inches,  and  has  tapered  to  an  apex  at  or  beyond  the 
pylorus.  The  passage  through  the  pylorus  may  be  quite 
impermeable,  or  capable  of  admitting  a  probe.  Looked  at 
from  the  duodenal  side,  the  pyloric  mass  bears  a  close 
resemblance,  frequently  remarked  by  authors,  to  the  projec- 
tion of  the  cervix  uteri  into  the  vagina.  The  mucous 
membrane  is  everywhere  thrown  into  folds.  The  tumour 
may  be  due  to  fibrous  thickening  of  the  submucous  coat,  to 
hypertrophy  of  the  circular  or  longitudinal  muscular  coats, 
or  to  any  combination  of  these. 

No  satisfactory  explanation  of  the  aetiology  of  the  disease 
has  yet  been  put  forward. 

The  following  views  have  been  held:  i.  That  the  hyper- 
trophy is  the  result  of  spasm  from  some  irritant  in  the 
stomach.  2.  That  it  is  a  developmental  overgrowth. 
3.  That  it  is  a  result  of  the  congenital  narrowing  of  the 
lumen  of  the  pylorus,  followed  by  compensatory  hypertrophy 
of  the  stomach.  4.  That  it  is  a  functional  disorder  of  the 
nerves  of  the  stomach  and  pylorus,  leading  to  an  ill  co- 
ordination, and  therefore  an  antagonistic  action  of  their 
muscular  arrangement. 


44  SURGERY  OF  THE  STOMACH 

Treatment. 

Rectal  and  nasal  (to  avoid  the  peristalsis  set  up  by  degluti- 
tion) feeding  have  been  advocated  for  the  slighter  cases.  The 
severer  cases  must  be  submitted  to  operation,  as  first  sug- 
gested b}-  Schwyzer. 

The  first  successful  operation  was  recorded  by  W.  Abel 
{Miinchen.  Med.  Wochen.,  November,  1899).  The  patient  was 
a  male  infant,  eight  weeks  old,  and  anterior  gastro-enter- 
ostomy  was  performed.  Nicoll  recorded  (British  Medical 
Journal,  September,  1900)  the  second  successful  case,  Loreta's 
operation  being  performed.  Kehr  relates  two  recoveries  after 
operation  in  children,  nine  weeks  and  six  months  old. 
Monnier  {Dent.  Zeit.  f.  Chir.,  1901)  states  that  a  successful 
case  of  gastro-enterostomy  which  he  relates  is  the  sixth. 

Unsuccessful  cases  of  gastro-enterostomy  are  recorded 
by  Meltzer,  Stern,  Adler  and  Thomson.  A  fatal  case  of 
pylorectomy  is  also  recorded  by  Thomson.  The  operation 
of  choice  in  all  such  cases  is  clearly  gastro-enterostomy. 
Pyloroplasty,  on  account  of  the  great  thickness  of  the  pylorus 
and  its  rigidity  in  the  whole  circumference,  is  inapplicable. 
Pylorectomy  is  unnecessarily  severe.  Gastro-enterostomy  is 
quicker  and  probably  much  safer.  Murphy's  button  should 
on  no  account  be  used  to  effect  the  anastomosis. 

Congenital  Atresia  of  the  Pylorus, 

Hammer  (quoted  by  Nicoll,  loc.  sup.  cit.)  distinguished 
between  congenital  stenosis  characterized  by  great  thickening, 
and  congenital  atresia,  in  which  no  thickening  is  found.  He 
describes  a  case  of  congenital  atresia  in  which  the  pyloric 
end  of  the  stomach  and  the  upper  end  of  the  duodenum 
formed  culs-de-sac  abutting  on  one  another,  and  united  by  a 
fibrous  band  in  which  there  was  ultimately  found  an  exceed- 
ingly fine  channel,  which,  however,  had  proved  impervious 
to  fluid  under  pressure,  used  as  a  test. 

The  disease  has  in  all  recorded  examples  run  a  rapidly 
fatal  course.  If  diagnosed  early,  it  should,  nevertheless, 
prove  amenable  to  surgical  treatment. 


CHAPTER  III 

INJURY  OF  THE  STOMACH 

Wounds  of  the  stomach  may  be  incised,  lacerated  or  gun- 
shot. Incised  (punctured)  wounds  are  caused  by  stabs  with 
sharp-pointed  instruments  of  metal  or  wood.  Lacerated 
wounds  are  the  result  of  severe  contusions,  kicks,  blows  with 
the  fist,  falls,  or  buffer  accidents.  The  stomach  is  less 
frequently  injured  than  the  intestine,  owing  to  its  protection 
by  the  chest-wall  and  liver.  The  stomach  may  also  rupture 
spontaneously  or  by  injury  from  within. 

A  wound  of  the  stomach  may  involve  the  mucous  coat 
alone,  the  mucous  and  muscular,  the  muscular  and  serous, 
the  serous  alone,  or  all  the  coats ;  it  may  or  may  not  be 
associated  with  a  wound  of  the  abdominal  wall,  and  may  be 
found  on  either  the  anterior  or  the  posterior  surface.  The 
symptoms  will  vary  according  to  the  nature  and  extent  of 
the  wound.  If  the  mucous  surface  alone  is  wounded,  gastror- 
rhagia  of  greater  or  less  severity  will  be  noticed.  In  some 
cases  there  has  been  copious  vomiting  of  bright  arterial 
blood,  showing  that  a  vessel  of  some  size  has  been  wounded. 
If  the  serous  coat  alone  is  torn,  there  will  be  a  localized 
peritonitis,  which  may  possibly  lead  to  a  perigastric  abscess. 
If  a  complete  solution  of  all  the  coats  occurs,  the  symptoms 
and  signs  will  depend  in  some  degree  upon  the  amount  and 
character  of  the  food  present  in  the  viscus.  If  the  stomach 
be  empty,  the  extravasated  fluid  will  consist  of  gastric  juice, 
with  remnants  of  food  and  mucus,  and  it  will  be,  com- 
paratively speaking,  innocuous.  If  the  stomach  be  laden 
with  recently-acquired  food,  the  material  escaping  into 
the    peritoneal    cavity    will    be    abundant    in    quantity,    and 


46  SURGERY  OF  THE  STOMACH 

will  contain  various  forms  of  micro-organisms.  Septic  peri- 
tonitis will  result  in  either  case,  but  the  measure  of  its 
virulence  will  depend  upon  the  quantity  and  character  of  the 
extravasation.  The  symptoms  following  immediately  upon 
the  receipt  of  the  mjury  are  pain,  collapse  and  haematemesis. 

Pain  is  of  widely  varying  intensity,  but  is  generally  severe  ; 
the  whole  of  the  abdomen,  but  especially  the  umbilical  and 
epigastric  regions,  are  sensitive  and  tender.  Any  attempt  at 
movement  excites  or  increases  the  suffering.  The  pain  may 
pass  upwards  to  the  sternal  region,  or  laterally.  Shortness 
of  breath  or  difficulty  of  breathing  are  often  mentioned  as 
appearing  early. 

Collapse  is  sometimes  immediate  and  profound,  and  is  then 
due  to  haemorrhage  from  a  large  vessel.  The  pulse  is  rapid, 
thin,  compressible,  the  skin  cold  and  pallid ;  there  is  a 
bursting  forth  of  sw-eat  over  all  the  body.  Gradually  the 
abdomen,  at  first  held  rigid  and  tense,  becomes  swollen,  and 
the  signs  of  a  general  peritoneal  infection  swiftly  assert  them- 
selves. 

Haematemesis  is  the  most  important  symptorn.  It  may  be 
noticed  immediately  after  the  accident,  or  only  after  the 
lapse  of  an  hour  or  more.  Clayton  records  a  case  of  per- 
sistent haematemesis,  after  a  crush,  from  which  the  patient 
died  ;  a  laceration  of  the  mucous  membrane  of  the  stomach 
was  found. 

The  following  case  occurred  to  one  of  us  (A.  W.  M.  R.)  : 

H^MATEMESIS      FOLLOWING      ON      StAB     WoUND     OF      AbDOMEN  : 

Abdominal  Section. 

On  January  27,  1897,  a  young  mechanic,  aged  twenty,  was 
admitted  to  the  Leeds  General  Infirmary  after  vomiting  of  bright 
blood  following  on  a  stab  wound  of  the  abdomen,  the  wound 
having  been  inflicted  by  a  long,  fine,  triangular  file  that  had 
caught  in  the  lathe  at  which  the  youth  had  been  turning. 

On  admission  he  was  pale  and  collapsed,  with  a  pulse  of  190 ; 
and  as  there  were  signs  of  free  fluid  in  the  peritoneal  cavity,  it 
was  thought  that  the  stomach  had  been  perforated,  and  that  the 
bleeding  was  from  a  ruptured  gastric  artery. 

On  opening  the  abdomen  a  large  quantity  of  blood  and  clot 
was  found  free  in  the  abdominal  cavity,  and  in  the  kidney  pouches 


INJURY  OF  THE  STOMACH  47 

and  pelvis,  but  on  carefully  examining  the  stomach  no  perforation 
could  be  found.  After  some  searching  the  superior  mesenteric 
vein  was  found  bleeding  freely,  the  file  having  bruised  and  pushed 
aside  the  stomach,  pierced  the  great  omentum,  and  then  wounded 
the  vein. 

The  abdomen  was  washed  out  wdth  hot  water  after  the  vein 
had  been  ligatured,  and  this  also  arrested  the  gastrorrhagia,  as 
the  patient  made  a  good  recovery  and  had  no  further  haemate- 
mesis.  The  shock  was  relieved  by  the  infusion  of  3  pints  of 
normal  saline  solution  into  the  median  basilic  vein,  and  by 
injections  of  liq.  strychniae. 

The  bleeding  was  evidently  from  bruising,  and  possibly  lacera- 
tion of  the  mucous  coat  of  the  stomach,  and  not  from  a  large 
vessel,  as  it  was  apparently  arrested  by  the  hot  lavage,  without 
any  actual  operation  on  the  stomach  itself. 

If  the  wound,  or  the  chief  of  several  wounds,  is  on  the 
posterior  surface  of  the  stomach,  the  symptoms  and  signs 
are  equivocal,  and  a  localized  effusion  in  the  lesser  bag  will 
result.     The  first  case  of  this  kind  was  recorded  b}-  E.  Rose. 

Rehn  of  Frankfort  related,  at  the  German  Surgical  Congress 
of  1896,  the  case  of  a  girl,  aged  nineteen,  who  fell  some  distance 
heavily  on  to  the  abdomen.  The  symptoms  suggested  injury  to 
the  stomach.  A  laparotomy  was  performed  five  hours  after 
the  accident.  A  turbid  fluid  escaped  through  the  incision.  On 
the  anterior  wall  of  the  stomach  w^ere  two  wounds,  which  involved 
the  serous  and  muscular  coats.  A  tear  was  seen  in  the  great 
omentum  close  to  the  stomach,  from  which  fluid  issued.  This 
opening  was  cautiously  enlarged,  and  the  posterior  wall  of  the 
stomach  exposed.  A  wound  4  inches  in  length  was  then  laid  bare, 
involving  all  the  coats  of  the  posterior  wall  of  the  stomach.  This 
was  stitched,  a  w^ound  in  the  spleen  sutured,  and  the  abdomen 
closed. 

After-Results. 

As  a  general  rule,  a  wound  of  the  mucous  membrane  of 
the  stomach  heals  readily.  Cases,  however,  are  recorded  by 
Lebert,  Brinton,  Fenwick,  and  others,  of  acute  ulceration  of 
the  stomach  following  immediatelyupon  injury  in  previously 
healthy  individuals ;  and  Potain  relates  one  example  in 
which  the  ulcer  became  chronic. 


48  SURGERY  OF  THE  STOMACH 

Gunshot  Wounds  of  the  Stomach. 

The  experience  in  the  South  African  War  has  shown 
bevond  doubt  that,  with  small-cahbre  bullets  moving  with 
high  velocit)',  a  gunshot  wound  of  the  stomach  will  in  almost 
every  instance  recover  without  operative  interference.  The 
further  history  of  men  so  wounded  has  yet  to  be  written,  and 
evidence  is  not  lacking,  in  our  experience,  which  goes  to  show 
that  such  history  is  not  uneventful.  Complaint  of  indefinite 
pains  in  the  upper  part  of  the  abdomen,  digestive  disturb- 
ances, and  so  forth,  have  been  met  with  in  two  cases  in  our 
experience,  but  the  patients  did  not  remain  sufficiently  long 
under  observation  to  warrant  any  positive  statement.  But  the 
lessons  of  the  war  do  not  apply  in  civil  practice.  The  gunshot 
wounds  of  the  abdomen  we  meet  with  are  inflicted  most 
commonly  by  rude  and  uncertain  weapons — '  toy  '  pistols  or 
revolvers.  Such  wounds  are  ragged  and  contused,  and  do 
not  heal  spontaneously.  The  rule  should  therefore  be  in 
all  cases  to  operate.     Exploration  is  safer  than  uncertainty. 

Injury  of  the  Stomach  from  within. 

There  are  on  record  a  number  of  cases  of  spontaneous 
rupture  of  the  stomach — of  rupture,  that  is,  independent  of 
ulcer  or  carcinoma,  or  other  visible  disease.  Such  a  bursting 
results  from  overdistension.  Arton  reports  a  case  in  a  negro 
aged  fifty  3'ears.  Fulton  mentions  a  case  of  rupture  of  the 
oesophageal  end  of  the  stomach  in  a  child  owing  to  disten- 
sion. Collins  describes  a  spontaneous  rupture  in  a  woman 
sevent3'-four  years  of  age  ;  this  was  followed  by  collapse  and 
death,  and  a  necropsy  showed  a  rupture  2  inches  long, 
about  2  inches  from  the  pyloric  extremity.  The  records  of 
St.  Bartholomew's  Hospital  contain  the  account  of  a  man, 
thirty-four  years  of  age,  who  for  two  years  had  been  the 
subject  of  paroxysmal  pain  in  the  stomach.  At  the  hospital 
he  had  an  attack  of  vomiting  after  a  debauch,  and  after  a 
sudden  attack  of  pain  at  the  pit  of  the  stomach  he  died.  A 
ragged  opening  on  the  surface  of  the  stomach  near  the 
cardiac  extremity  was  found  post-mortem,  there  being  no  signs 
of  gastric  ulcer  or  cancer.     Clarke  (Indian  Medical  Gazette, 


INJURY  OF  THE  STOMACH  49 

1885)  reports  two  cases — one  in  a  Hindoo,  twenty-two  years 
of  age,  and  another  in  a  woman  who  was  supposed  to  have 
died  from  cholera.  Recovery  probably  never  occurs  naturally 
in  these  spontaneous  ruptures. 

Perforation  may  occur  from  within,  as  in  the  case  of  sword 
and  knife  swallowers.  A  remarkable  case  of  this  kind 
occurred  at  Guy's  Hospital  in  1807.  After  death  there  were 
thirty  or  forty  fragments  of  knives  found  in  the  stomach, 
one  of  which  had  transfixed  the  colon  and  the  rectum. 
Needless  to  say  that  in  all  these  cases  the  sooner  after  the 
injury  the  patient  is  treated  the  greater  will  be  the  chance  of 
recovery. 

Treatment. 

In  ever}^  case  of  wound  of  the  stomach,  however  pro- 
duced, in  which  all  the  coats  are  involved,  operation  should 
be  resorted  to  at  the  earliest  moment. 

If  any  doubt  be  felt  as  to  the  existence  of  a  perforating 
wound  of  the  stomach,  the  oesophageal  tube  may  be  passed, 
and  the  stomach  inflated  with  air.  If  the  organ  is  intact  it 
will  distend,  and  its  outline  will  be  plainly  visible  ;  if  burst, 
the  gas  will  escape  into  the  peritoneal  cavity,  and  probably 
cause  an  immediate  loss  in  the  liver  dulness. 

The  abdomen  will  be  opened  through  a  central  incision, 
and  the  stomach  at  once  exposed.  Careful  search,  both  on 
the  anterior  and  posterior  surfaces,  must  be  made,  and  the 
entire  organ  examined.  If  the  wound  be  small,  the  bubbling 
of  fluid  or  gas  through  the  aperture  will  at  once  indicate  its 
locality  ;  if  large,  there  will,  of  course,  be  little  or  no  difficulty 
in  discovering  it.  The  wound  should  be  stitched  up  with  a 
continuous  suture  of  catgut,  including  the  mucous  membrane 
alone  or  all  the  coats,  and  a  suture  of  silk  picking  up  the 
serous  coat  only.  If  there  has  been,  as  in  gunshot  wound,  a 
destruction  of  a  portion  of  the  wall  of  the  stomach,  an 
omental  flap  or  graft  may  be  usefully  employed  to  close  the 
resulting  gap.  Enderlen  has  recently  shown  {Dent.  Zcit.  f. 
Chir.,  1900)  experimentally  in  the  cat  that,  when  a  portion  of 
the  stomach  wall  is  excised,  there  is  a  free  prolapse  of 
mucous  membrane.     To  the  cut  edges  of  mucous  membrane 

4 


50  SURGERY  OF  THE  STOMACH 

he  stitched  a  graft  of  omentum,  and  the  gap  in  the  serous 
coat  was  then  closed  by  a  large  omental  flap.  The  experi- 
ment proved,  not  only  that  the  transplantation  succeeded, 
but  that  the  omental  tissue  gradually  assumed  the  character 
of  gastric  mucous  membrane,  and  well-formed  glands 
developed. 

Care  must  in  all  cases  be  taken  to  insure  that  a  wound  of 
the  posterior  surface  is  not  overlooked.  It  would,  we  think, 
be  a  safe  and  wise  precaution  in  all  operations  to  turn  the 
great  omentum  upwards,  tear  through  the  transverse  meso- 
colon, and  expose  the  posterior  surface  of  the  stomach,  as  in 
Von  Hacker's  operation.  The  existence  of  multiple  wounds 
must  be  always  contemplated  as  a  possibility.  In  one 
reported  case  there  were  no  less  than  three  wounds  in  the 
stomach,  two  of  which  were  sutured  ;  the  third,  being  un- 
discovered, led  to  death  from  peritonitis. 

Dr.  G.  Woolsey  reports  a  case  of  wound  from  a  pistol 
bullet  in  which  he  had  successfully  sutured  two  wounds  of 
the  stomach,  two  of  the  transverse,  and  two  of  the  ascending, 
colon. 


'  Kopfstein  has  related  the  case  of  a  schoolboy  who  shot  himself 
in  the  stomach  playing  with  a  revolver.  It  was  about  one  o'clock 
in  the  day,  shortly  after  a  meal,  when  the  accident  occurred,  and 
he  was  straightway  taken  to  hospital.  The  abdomen  was  not 
found  to  be  tender  ;  the  pulse  was  accelerated,  vomiting  present, 
and  the  patient  was  very  pale.  The  wound  was  observed  in  the 
parasternal  line,  and  deviating  towards  the  left,  directly  under  the 
margin  of  the  ribs. 

'  One  hour  later  it  was  resolved  to  perform  laparotomy.  The 
abdomen  was  freely  opened  in  the  median  line,  and  the  whole  of 
the  stomach  to  the  left  laid  bare.  On  the  upper,  or  convex,  side 
of  the  liver  a  star-shaped  mass  of  blood  was  found  on  the  peritoneal 
covering,  which  was  continued  into  the  parenchyma  of  the  organ 
as  far  as  the  sound  would  go  without  injury.  A  sharp-cut  per- 
foration was  present  in  the  stomach,  admitting  the  free  passage  of 
a  pencil,  with  no  prolapse  of  mucous  membrane,  which  is  often 
assumed  to  close  these  wounds  rapidly.  Close  to  the  wound  in 
the  gastric  wall  a  large  vessel  was  seen  pulsating  ;  none  of  the 
stomach  contents  were  observed  in  the  liver  or  the  track  of  the 
bullet. 


INJURY  OF  THE  STOMACH  51 

'The  hepatic  hemorrhage  was  checked  by  "  Paquelin,"  and  the 
walls  of  the  stomach  were  closed  with  Lembert's  sutures. 

'  The  stomach  was  then  lifted  up  and  its  posterior  aspect 
examined,  but  nothing  abnormal  could  be  found.  The  abdomen 
was  then  washed  out,  and  the  wound  closed  in  three  stages. 

'  After  the  operation  he  vomited  once.  Temperature,  37*7°  Cent., 
equals  99'86°  Fahr.  ;  pulse,  120.  Next  day  he  took  fluids  with 
comfort.  The  first  dressing  was  removed  twelve  days  after  the 
operation,  and  the  patient  dismissed  from  hospital  twenty  days 
after  admission.' — Medical  Press,  igoo. 


4—2 


CHAPTER  IV 


SIMPLE  TUMOURS  OF  THE  STOMACH. 


These  tumours  are  rare.  Their  clinical  importance  is  small, 
and  their  symptoms,  though  frequently  trifling  and  quite 
inconspicuous,  may  suggest  a  diagnosis  of  pyloric  stenosis  or 
cancer.     The  following  forms  are  known  : 

1.  Adenoma. 

2.  Lymphadenoma. 

3.  Lipoma.     Lipo-myoma. 

4.  Myoma.     Fibro-myoma. 

5.  Cysts. 

I.  Adenoma  may  be  found  at  any  portion  of  the  stomach, 
though   it  is  most   commonly  found   near  the  pylorus.     At 


Fig.  6. — Villous  Growth  near  Lesser  Curvature,  found  Post-mortem 
IX  AN  AGED  Woman. 

(No.  2,407«,  Royal  College  of  Surgeons'  Museum.) 

first  a  rounded,  smooth  projection  is  formed  on  the  surface 
of  the  organ  ;  graduall}-,  owing  to  a  narrowing  at  the  peri- 


SIMPLE  TUMOURS  OF  THE  STOMACH  53 

phery,  the  little  tumour  becomes  pedunculated,  and  then 
hangs  pendulous  from  a  narrow  stalk.  One  of  us,  in 
operating  upon  such  a  case,  was  able  to  see  the  cherry- 
shaped  nodule  carried  on  into  the  pylorus,  which  it  blocked 
with  the  completeness  of  a  ball-valve.  When  the  tumour 
is  of  large  size  it  may  form  a  readily-palpable  mass  of 
extreme  mobility,  generally  situated  above  the  umbilicus, 
but  occasionally  descending  below  it.  According  to  Sutton, 
these  tumours  are  sometimes  '  so  mobile  that  they  may  be 
shifted  into  all  the  regions  of  the  abdomen.' 


Fig.  7. — Polypus  near  Pylorus,  which  caused  Death  by  Vomiting. 

The  patient  was   a  woman   aged  ninety-two.      (No.  2,405^,    Royal    College  of 
Surgeons'  Museum.) 


Adenoma  of  Stomach  (under  the  care  of  Dr.  Hinds, 
Worthing,  who  has  kindly  supplied  us  with  the  accompany- 
ing notes)  : 

'  iV.  C,  female,  sixty-eight  years  of  age.  Complained  of  pain- 
ful "  gripings  "  in  the  stomach  and  frequent  action  of  the  bowels 
at  irregular  times  ;  she  had  wasted  and  was  unable  to  work.  On 
examination  of  the  abdomen  a  hard  tumour  was  felt  in  the  epi- 
gastrium, freely  movable  and  capable  of  being  pushed  to  the  left 
of  the  spine  as  low  as  the  umbilicus,  and  to  the  back  under  the 
right  ribs,  where  it  was  lost. 

'  Operation. — Median  incision  ;  the  tumour  was  found  to  be 
within  the  stomach.  The  anterior  wall  of  the  stomach  was 
opened,  and  a  tumour  the  size  of  a  golf-ball  found  attached  to 


54 


SURGERY  OF  THE  STOMACH 


the  posterior  wall  by  a  base  about    i   inch  in   diameter,  which 

involved   the   pyloric   opening.      The   tumour  was  removed  by 

cutting  through  the  mucous  membrane  around  the  base,  but  at 

one  point  the  posterior  wall  at  the  junction  of  the  stomach  and 

duodenum   was   opened ;    bleeding   was    slight.      The    posterior 

wound    was    closed     from    within     the 

stomach.      The  patient  recovered   from 

the  operation,  and  was  well  for  twelve 

months,  putting  on  flesh,  and  returning 

/  ^.  '  to  her  work.    Then  sickness,  flatulence, 

Y  \  and  a  feeling  as  if  the  food  "  could  not 

/         /  .  get  past  somewhere,"  with  wasting  and 

J      ^  .        '.  inability  to  work.     Gastro-enterostomy 

mb^      ^J  C^iv^  by  Von  Hacker's  method  was  performed 

■        *•■-  W*^-  eighteen   months   after  the  first  opera- 

*^J'- :  tion,  but  the  patient  died  of  exhaustion 

in  forty-eight  hours.     At  the  autopsy  an 

ulcer  f  inch  in  diameter,  invohdng  the 

pylorus,  was  found.     There  was  no  sign 

of  sfrowth.' 


\ 


( 


.■>♦ 


Hayem  describes  two  cases  of 
adenomatous  growth,  the  structure 
of  which  resembled  Brunner's  glands, 
chiefly  affecting  the  submucosa.  The 
growth  appears  to  be  derived  from 
the  glandular  cul-de-sac  of  the 
mucosa,  but  it  rapidly  passes  through 
the  muscularis  mucosae,  and  de- 
velops in  the  submucous  tissue.  In 
Hayem's  cases  the  adenoma  was 
associated,  in  the  first  with  the  per- 
foration of  an  ulcer,  and  in  the  second 
with  malignant  disease.  Hayem  re- 
gards them  as  benign  tumours  which 
may  become  malignant. 
A  case  of  adenoma  simulating  cancer  w^as  shown  in  1894 
to  the  Societe  de  Chirurgie  at  Paris  by  Chaput.  The  patient 
was  a  man  aged  sixty-four.  The  symptoms  were  chiefly 
emaciation,  vomiting  of  coffee-ground  material,  and  an  epi- 
gastric tumour  was  observed.     At  the  operation  an  adenoma 


Fig.  8. — Polypi  Growing 

FROM     THE     Mucous 

Membrane  of  the 
Stomach  of  a  Gentle- 
man, seventy-six  years 
of  age,  who  suffered 
from  Constant  Dys- 
pepsia. 

(No.  2,405,  Royal  College  of 
Surgeons'  Museum  ) 


SIMPLE  TUMOURS  OF  THE  STOMACH 


55 


covered  with  normal  mucous  membrane  was  found  attached 
by  a  small  pedicle  to  the  posterior  w^all  of  the  stomach. 

Adenomata  are  occasionally  multiple.  Adenoma  and 
malignant  disease  may  be  present  in  the  same  stomach 
(Leeds  Museum). 

2.  Lymphadenoma.. — A  rare  form  of  tumour,  characterized 
by  exuberant  polyposis  of  the  mucous  membrane.  A  very 
good  example  is  described  and  figured  b}'  Pitt  {Trans.  Path. 
Soc,  1889).  Several  masses  of  growth  projected  into  the 
cavity  of  the  stomach,  one  measuring   2   inches  across  and 


Fig.   9.— Polypus  near   Pylorus    Fig.    10.— Adenoma    Removed    from 

WHICH   CAUSED    FATAL   InTUSSUSCEP-  StOMACH. 

TION  OF  DUODEXUM  IN  A  Man  AGED  rQj.^  Hind's  Case.) 

Twenty-one. 

(No.   2,4051:,  Royal  College  of  Surgeons' 
Museum.) 

I  inch  thick.  Norman  (Dublin  Journal  of  Medical  Science, 
vol.  xcv.)  reports  a  case  in  which  symptoms  were  absent. 
The  mucous  membrane  was  everywhere  thickened,  and 
presented  all  varieties  of  polyposis,  from  large  dendriform 
projections  to  small  wartlike  growths. 

3.  Lipoma. — Lipomata  are  occasionally  found  in  the  sub- 
mucous layer  of  the  stomach  near  the  pylorus.  Such  a 
specimen  is  figured  in  \'irchow's  work  ('  Die  Krankhaft. 
Geschwiilste  '). 

A  case  of  lipomyoma  is  reported  by  Kunze  {Ann.  of  Univ. 
Med.  Sci.,  i8gi).  The  patient  was  a  man  aged  fifty-two, 
who  complained  of  a  tumour  in  the  epigastrium.     The  chief 


56 


SURGERY  OF  THE  STOMACH 


points  remarked  were  that  the  swelHng  was  hard,  nodular, 
and  extremely  mobile.  There  were  no  stomach  symptoms. 
A  diagnosis  of  mesenteric  tumour  was  made  and  an  ab- 
dominal section  performed.  The  growth  was  found  in  the 
anterior  wall  of  the  stomach  at  the  cardiac  end.  The 
patient  succumbed  in  fifteen  da3'S. 

4.  Myoma  and   Fibro-myoma, — These   forms  are   generally 
found  as  prominent,  rounded,  hard  swellings  in  the  coats  of 


Fig.  II. 


-Malignant  Plaque  in  Stomach  Wall — Polypoid  Growth  at 
THE  Pylorus. 


the  stomach.  They  may  in  their  enlargement  become 
pedunculated  and  project  either  towards  the  mucous  or  the 
serous  coat  of  the  stomach,  forming  the  varieties  known  as 
'  internal '  and  '  external.'  Wilks  and  Moxon  state  that 
'  cases  are  recorded  where  a  polypus  of  this  kind  has  been 
vomited  up.'  These  tumours  grow  slowly,  are  smooth  or 
nodular  upon  the  surface,  and,  if  projecting  into  the  stomach, 
are  attended  by  haemorrhage. 

Myoma  of  the  stomach  was  first  observed  in  1762  by 
Morgagni.  Vogel  in  1845,  Forster  in  1858,  and  Sangalli  in 
i860,  recorded  examples. 


SIMPLE  TUMOURS  OF  THE  STOMACH 


57 


Herhold  {Deutsche  Med.  Wochensch.,  1898,  No.  4)  records 
an  example  of  myoma  in  a  woman  thirty-seven  years  of  age. 
There  was  a  three  years'  history  of  intractable  vomiting 
occurring  soon  after  food.  The  stomach  was  moderately 
dilated  and  the  vomit  contained  free  HCl.     As  there  was  a 


lwa>'li-i  \   ■ 

Fig.  12. — Lymphadexoma  of  Stomach. 

history  pointing  to  old  peritonitis,  it  was  supposed  that  there 
were  adhesions  pulling  on  the  pylorus.  On  opening  the 
abdomen,  a  tumour  was  found  in  the  pyloric  region  of  the 
stomach  of  the  size  of  a  hazel-nut,  obstructing  the  duodenum 
to  a  moderate  degree.  The  tumour,  which  was  removed, 
proved  to  be  a  myoma. 


58  SURGERY  OF  THE  STOMACH 

The  following  cases  are  also  recorded  : 
Ruprecht   of    Dresden    {Archiv.  f.    Klin.   Chir.,    Bd.    40) 
removed  a  m}-oma,   10  centimetres  by  7  centimetres,  from 
the    anterior   wall    of  the    stomach    near   the   cardia.      The 
patient  died  of  pneumonia. 

Von  Erlach  {Wien.  Klin.  Woch.,  1895,  No.  15)  removed  an 

enormous  myoma  weighing  5I  kilo- 
grammes from  the  anterior  wall  of 
■^       '  the  stomach  with  success. 

The  successful  removal  of  a  very 
large  fihro-myoma  has  been  accom- 
plished by  Professor  von  Eisels- 
berg.  The  growth  was  '  the  size  of 
a  man's  head,'  and  hung  down- 
wards from  the  greater  curvature. 
The  portion  of  the  stomach  bear- 

Fio.    13.  —Villous    Growth   ing  it  was  also  removed  {Archiv. f. 
NEAR     Lesser     Curvature,    j.^,.      ^,  .       -p,       1   „    x 
FOUND  Post-mortem.  ^^^«-  Chir.,  Band  54). 

(No.  2,4o7«,  Royal  College  of  Sur-  Nicoladoni  has  also  removed  a 
geons' Museum.)  myoma   of    the  stomach   (Steiner, 

Beit.  z.  Klin.  Chir.,  22).  The  patient  was  in  extremis,  and 
died  from  purulent  peritonitis.  An  area  of  the  stomach  wall, 
26  centimetres  by  14  centimetres,  w^as  removed  from  near  the 
greater  curvature. 

Altogether,  nineteen  cases  are  recorded  in  surgical  litera- 
ture. Of  these,  eleven  are  external,  six  internal,  and  in  two 
details  are  not  given.  Of  the  eleven  external,  seven  grew 
from  the  greater  curvature,  one  from  the  lesser,  one  on  the 
anterior  wall,  and  tw^o  from  near  the  pylorus.  The  external 
growths  are  generally  not  recognised  as  arising  from  the 
stomach  until  an  operation  is  performed  for  their  removal. 

Myosarcoma  is  described  by  Virchow  and  Brodowski. 

5.  Cysts. — Wilks  and  Moxon  describe  a  case  of  cyst  in  the 
walls  of  the  stomach  of  about  the  size  of  a  walnut.  Cysts 
of  small  size  from  dilatation  of  the  glands  are  not  very 
infrequent. 

Ziegler  has  recorded  a  case  occurring  in  the  Munich  Clinic 
in  which,  as  the  result  of  an  injury,  a  tumour  formed  in  the 
walls  of  the  stomach.      Laparotomy  was  performed,  and  a 


SIMPLE  TUMOURS  OF  THE  STOMACH  59 

cyst  found  lying  between  the  muscular  and  mucous  coats  of 
the  stomach.     The  cyst  was  emptied,  and  did  not  refill. 

In  the  Trans.  Path.  Soc,  1857,  Mr.  J.  Hutchinson  describes 
a  cystic  tumour  of  the  stomach  the  size  and  shape  of  a 
walnut,  situated  near  the  pylorus,  between  the  peritoneal 
and  muscular  coats. 

H.  Read  {Medical  Record,  1882)  records  the  case  of  a  man 
aged  sixty-two  who  died  after  an  illness  of  five  weeks.  At 
the  autopsy  a  large  cyst  was  found  completely  encircling  the 
stomach.  It  contained  clear  fluid  and  lumps  of  fatty  sub- 
stance, with  black  streaks  of  extravasated  blood. 

Anderson  {British  Medical  Journal,  1898)  gives  an  account 
of  a  case  of  multiple  cysts  of  the  stomach  and  intestines, 
which  he  believed  '  originated,  after  the  fashion  of  dermoids, 
from  inclusion  or  embryonal  rests  left  over  in  the  process  of 
development  of  the  alimentary  canal.' 


CHAPTER  V 


CANCER  OF  THE  STOMACH 


Pathological  Anatomy. 

Carcinoma  of  the  stomach  is  either  primary  or  secondary. 
The  primary  form  alone  is  of  interest  to  the  surgeon. 

The  classification  of  carcinoma  which  is  at  once  the 
simplest  and  most  accurate  is  that  adopted  by  Perry  and 
Shaw  in  their  admirable  paper  in  the  Guy's  Hospital  Reports 
(i8gi).  They  describe  cylindrical  earcinomata,  including  the 
forms  variously  termed  adeno-carcinoma,  cylinder-epithe- 
lioma,  or  destructive  adenoma,  and  spheroidal  earcinomata. 
If  the  fibrous  stroma  is  abundant,  the  term  '  scirrhus  '  is 
applied  ;  if  scanty,  the  term  '  medullary.'  In  both  varieties 
the  cells  are  liable  to  colloid  degeneration.  The  cylindrical 
earcinomata  are  more  amenable  to  surgical  treatment.  They 
are  slower  in  rate  of  growth,  and  they  do  not  develop  ad- 
hesions at  an  early  period. 

Situation. — Cancer  may  be  found  at  any  part  of  the  organ. 
Gussenbauer  states  that  in  60  per  cent,  of  cases  the  growth 
is  in  the  pyloric  region,  in  30  per  cent,  in  the  body,  and 
in  10  per  cent,  at  the  cardia.  Lebert  gives  the  following 
percentages  : 


Pylorus 

.     54  per  cent 

Lesser  curvature 

•      16 

Cardia 

•       9       » 

Anterior  wall 

3 

Posterior  wall 

4 

Both  walls    ... 

4 

Greater  curvature    ... 

4 

Diffuse           

•       6       „ 

CANCER  OF  THE  STOMACH  6i 

Furnivall  in  1,796  cases,  compiled  from  various  authors, 
found  the  pylorus  affected  in  i,tio,  the  lesser  curvature  in 
197,  the  cardiac  orifice  in  158,  and  the  rest  of  the  stomach  in 
331,  The  cardiac  area  is  rarely  affected  primarily  :  in  many 
cases  the  growth  extends  downwards  from  the  oesophagus  ; 
in  others  the  growth  spreads  from  the  body. 

Extension. — Adhesions  found  in  association  with  malignant 


Fig.  14. — The  Lymphatics  of  the  Stomach.     (After  Cun^o. 


disease  of  the  stomach  are  either  simple  in  character — the 
result  of  local  septic  inflammation — or  malignant.  Spread 
of  the  growth  away  from  the  stomach  may  occur  along  the 
line  of  adhesions,  by  direct  implantation  upon  a  neighbour- 
ing surface,  through  the  bloodvessels,  or  through  the  lym- 
phatic vessels,  which  drain  into  glands  situated  {a)  along 
the  whole  of  the  lesser  curvature  in  large  numbers ;  {h)  along 
the  greater  curvature,  chiefly  near  the  pylorus ;  (c)  a  few 
in  the  great  omentum  ;  (i)  near  the  head  of  the  pancreas. 


62 


SURGERY  OF  THE  STOMACH 


Cuneo    has    recently   made    an    exhaustive   examination    of 
specimens    of  mahgnant    disease   of  the  stomach,  and  the 

lymphatic  and  glandular  im- 
plication resulting  therefrom. 
The  points  of  especial  im- 
portance from  the  surgical 
standpoint  are  : 

1.  The  early  and  wide  ex- 
tension in  the  submu- 
cosa, 

2.  The  tendency  of  cancer 
to  drift  towards  the 
lesser  curvature. 

3.  The  habitual  integrity 
of  the  duodenum. 

I.  The    early  and  wide    ex- 
tension   in    the    submucosa    is 
well  seen  on  making  sections 
of  the  margin  of  the  growth. 
The     infiltration     of     the 
mucous      membrane      marks 
the  limit  of  induration.     Be- 
yond    this    there    is    a    con- 
tinuous layer    of   growth   in 
the  submucosa  for  some  dis- 
tance, which  gradually  thins 
off  and  becomes  broken  up, 
as  it  were,  so  that  the  growth 
for  several  centimetres  is  re- 
presented   by   scattered    and 
isolated  groups  of  cells.     The 
area  of  infiltration  of  the  mus- 
cular and  serous  layer  is  always 
less  than  that  of  the  mucosa. 
In    order    to    remove    the 
whole  disease,  the  line  of   section   must  be   at  a  minimum 
distance  of  3  centimetres  from  the  margin  of  the  induration. 
2.  The  tendency  of  cancer  to  drift  towards  the  lesser  curvature. 
In  eleven   specimens  an    extension   to  the  lesser  curvature 


Fig.  15. — Cancer  of  Cardiac  End 
OF  Stomach,  Associated  with 
Cancer   of    the  Lower  End   of 

THE    CESOPHAGUS. 

(No.   2,421,  Royal  College  of  Surgeons' 
Museum.) 


CANCER  OF  THE  STOMACH 


63 


was  found  in  nine.  The  stomach  along  the  curve  is  hardened, 
and  a  thick,  white,  cordUke  band  is  formed.  Glandular 
enlargement  is  found  always,  for  the  chief  lymph  current  is 
directed  towards  the  lesser  curvature.  The  thickening  ceases 
generally  at  the  point  where  the 
coronary  artery  reaches  the 
stomach — that  is,  where  the  lym- 
phatics also  pass  away. 

When  tne  glands  along  the 
lesser  curvature  are  all  infiltrated, 
the  only  method  of  extirpating 
them  is  by  removing  the  stomach 
wall,  to  which  they  are  attached. 

The  habitual  integrity  of  the  duo- 
denum was  first  pointed  out  by 
Rokitansky  and  Brinton.  Though 
growth  rarely  extends  far  into  the 
duodenum,  Carle  and  Fantino 
have  shown  that  islets  of  growth 
may  exceptionally  be  found  be- 
tween 2  and  3  centimetres  from 
the  pylorus.  The  section  of  the 
gut,  in  p3dorectomy,  should  be 
made  at  least  2  centimetres  from 
the  margin  of  the  induration. 

The  frequency  of  adhesions, 
glandular  enlargements  and  metas- 
tases has  been  variously  esti- 
mated. Gussenbauer  and  Wini- 
warter state  that  adhesions  are  present  in  63  per  cent. 
of  cases  of  pyloric  cancer  ;  Sutton  that  glandular  enlarge- 
ments are  found  in  50  per  cent,  of  cancer  affecting  any  part 
of  the  stomach ;  and  Gussenbauer  and  Winiwarter  that 
59  per  cent,  of  cases  show  metastatic  deposits.  McArdle 
collected  records  of  1,342  cases  of  cancer  of  the  stomach,  of 
which  802  were  limited  to  the  pyloric  region  ;  and  out  of  this 
number  496  were  not  associated  with  any  important  lymphatic 
involvement.  Lindner  records  28  recurrences  after  local 
removal  ;    of    these     15    were    local,    12    metastatic,    and 


Fig.  16. — Cancer  of  Cardiac 
End  of  Stomach  with  di- 
lated  CESOPHAGUS. 

(Xo.    2,417,    Royal    College    of 
Surgeons'  Museum.) 


64  SURGERY  OF  THE  STOMACH 

I  glandular.  These  figures,  which  are,  of  course,  drawn 
from  post-mortem  records,  are  evidence,  sufficiently  striking, 
of  the  local  character  of  malignant  disease  of  the  stomach — 
evidence  the  worth  of  which  is  borne  out  by  clinical  experi- 
ence, which  indubitably  goes  to  show  that  it  is  the  local 
growth  which  entails  the  suffering  and  determines  the  death 
of  the  patient. 

The  surger}'  of  carcinoma  of  the  stomach  must  in  the 
future  concern  itself  with  a  much  wider  local  removal.  It 
seems  not  unlikeh'  that,  in  order  to  secure  freedom  from 
local  recurrence,  the  lesser  curvature  up  to  the  point  where 
the  coronar}'  artery  reaches  the  stomach  will  in  all  cases 
have  to  be  removed.  By  so  doing,  the  chief  lymphatic 
vessels  and  glands  will  be,  of  necessity,  extirpated  also. 

Clinical  History  and  Symptoms. 

Cancer  of  the  stomach  affects  males  more  commonly  than 
females.  Welch  gives  the  proportion  as  five  to  four.  At  the 
Leeds  Infirmary,  during  ten  years,  there  werC:  thirty-six  males 
to  twenty-three  females.  Osier  in  150  cases  observed  126  males 
and  24  females.  The  age  of  patients  affected  is  generally 
between  fort}^  and  sixty  years  of  age,  though  no  period  of  life 
is  exempt.  Widerhofen  has  recorded  a  case  of  congenital 
carcinoma  of  the  stomach  ;  Cullingworth  has  observed  the 
^  ^  disease  in  a  child  of  five  weeks ;  and  one  of  us — Mayo  Robson 
»V^|     — has  operated  on  a  girl  of  twenty.     The  first  symptoms  of 

'^x^'^^this  disease  are  a  gradual  loss  of  appetite  and  wasting,  gener- 
ally, though  not  necessarily,  progressive,  coming  on  brusquely 
in  an  individual  previously  in  good  health.  Concomitant 
with  the  loss  of  flesh  is  a  sapping  of  the  strength   of  the 

Y_^/  patient.  He  becomes  anaemic,  listless,  disinclined  for,  and 
unequal  to,  any  exertion,  readily  tired.  Pain,  or  a  sense  of 
heaviness,  fulness  or  discomfort,  at  a  varying  interval  after 
food,  is  complained  of  early,  and  may  lead  to  a  feeling  of 
dislike  or  disgust  for  food.  In  not  a  few  cases,  however, 
despite  the  loss  of  health,  the  appetite  is  unimpaired,  but  a 
wary  and  wise  caution  is  observed  in  the  taking  of  food, 
because   of  the    known    penalties  which   follow   indulgence 


CANCER  OF  THE  STOMACH 


65 


Vomiting  of  food,  little  or  much  altered,  with  or  without 
blood,  or  of  blood  alone,  is  noticed  in  most  of  the  cases. 
The  early  symptoms,  then,  are  very  similar  to  those  of 
chronic  gastritis.  It  is,  however,  rare  to  elicit  a  history  of 
very  old-standing  stomach  disorder  ;  the  first  evidences  of 
local  disease  appear  suddenly  in  persons  of  perfectly  sound 
health  and  robust  digestion.  After  some  weeks  or  months  a 
palpable  tumour  develops  in  the  majority  of  instances,  and 


£ 


Fig.  17.— Cancer  of  Cardiac  Orifice  of  the  Stomach. 
(No.  2,422,  Royal  College  of  Surgeons'  Museum.) 

the  symptoms  then  become  pronounced.  The  difficulties  ot 
taking  and  digesting  food  are  increased,  wasting  is  rapid, 
and  cachexia  develops.  In  some  cases  a  remarkable  desicca- 
tion of  the  tissues,  the  result  of  the  copious  outpouring  of 
fluid  from  the  stomach  wall,  is  observed.  Thrombosis  of 
veins,  oedema  of  the  legs,  enlargement  of  the  supraclavicular 
and  other  glands,  are  evidences  of  the  approaching  end. 

Cases  of  cancer  of  the  stomach  may  be  acute,  running  all 
their  course  in  three  months  ;  or  latent,  giving  rise  to  no 
characteristic  signs  or  symptoms,  the  cause  of  illness  and 

5 


66  SURGERY  OF  THE  STOMACH 

death  being  accidentally  discovered  at  the  autopsy.  The 
former  constitute,  according  to  Osier,  lo  per  cent.,  and  the 
latter  5  per  cent.,  of  all  cases.  Lindner  and  Kuttner  record 
two  cases  presenting  symptoms  of  pulmonary  tubercle,  in 
which  carcinoma  of  the  stomach  was  accidentally  discovered 
at  the  autopsy,  the  lungs  being  healthy. 

The  most  important  of  these  symptoms  are  pain,  vomiting, 
and  the  presence  of  a.  tumour. 

Pain  is  the  earliest  and  most  constant  symptom.  At  the 
outset  of  the  disease  complaint  is  made  of  heaviness,  of  undue 
fulness,  of  a  feeling  of  oppression  and  distension  in  the 
epigastrium  after  food.  Pain,  limited  to  the  gastric  area  or 
radiating  to  one  or  the  other  side,  and  occasionally  pene- 
trating to  the  back,  soon  follows.  The  suffering  is  of  widely 
varying  intensity,  and  comes  at  a  shorter  or  longer  interval 
after  food.  We  have  noticed  in  not  a  few  cases  that,  as  with 
ulcer,  the  earlier  the  onset  of  pain  the  nearer  to  the  cardiac 
orifice  is  the  growth  situated.  In  a  small  minority  of  cases 
the  patients  assure  us  that,  at  least  in  the  earlier  stages,  the 
taking  of  food  has  given  ease,  as  in  hyperchlorhydria.  The 
severity  of  the  pain  is  liable  to  considerable  fluctuation  in 
the  same  patient,  and  individual  complaints  vary  much  in 
their  intensit}-.  It  is  not  often  that  the  pain  is  acute  and 
disabling. 

Vomiting  is  almost  as  constant  a  symptom  as  pain.  Ac- 
cording to  Osier,  it  is  present  in  85*3  per  cent,  of  patients. 
The  character  of  the  vomiting  depends  largely  upon  the  area 
of  the  viscus  affected.  In  pyloric  growth  with  obstruction 
and  consecutive  dilatation,  the  vomiting  is  copious  in  quantity, 
and  the  intervals  between  seizures  are  long.  Food  taken  a 
few  days  before  may  be  recognised  by  its  appearance  or  by 
flavour.  When  the  body  of  the  stomach  is  affected,  and  the 
capacity  of  the  organ  is  lessened,  the  vomiting  is  noticed 
soon  after — sometimes  immediately  after — food  has  been 
taken,  and  is  therefore  small  in  quantity,  becoming  progres- 
sively smaller.  In  cases  of  mural  cancer  the  vomiting  is 
not  usually  an  early,  and  from  the  statistics  of  Osier  would 
not  appear  to  be  so  pronounced  a  symptom. 

The  appearance  of  the  vomited  matter  will  depend  upon 


CANCER  OF  THE  STOMACH  67 

the  length  of  time  the  food  has  been  in  the  stomach,  and 
upon  the  presence  or  absence  of  adventitious  products,  such 
as  bile  or  blood,  ^^^hen  food  is  ejected  from  a  contracted 
stomach  during  or  immediately  after  a  meal,  the  appearance 
is  but  little  altered.  When  the  food  has  remained  a  day  or 
two  in  the  stomach,  the  vomited  matters  will  consist  of  pro- 
foundly altered,  ill-digested  food,  gastric  outpourings,  and 
probably  blood.  The  appearance  of  such  vomit  is  described 
by  the  epithet  '  coffee -ground.'     The  odour  is  faint  and  sour; 


Fig.  18. — Canxer  of  Pylorus,  Producing   Stenosis,  in  a  Woman  aged 

Thirty-six. 

(No.  2,4iifl',  Royal  College  of  Surgeons'  Museum.)     . 

when  sloughing  of  the  growth  takes  place,  the  smell  may  be 
extremely  offensive  and  penetrating.  Blood,  though  gener- 
ally intimately  mixed  with  the  stomach  contents,  may  be 
vomited  alone.  In  a  few  instances  it  has  been  the  first 
recorded  symptom  of  gastric  disease.  In  amount  it  varies 
from  a  mere  tinge  to  a  quantity  sufficient  to  cause  fainting 
and  anaemia.  Blood  poured  out  rapidly  into  the  stomach 
induces  immediate  vomiting  ;  when  slowly  escaping,  it  has 
time  to  undergo  partial  digestion,  and  its  appearance  becomes, 
therefore,  altered.  Death  rarely,  if  ever,  results  from 
hsemorrhage  alone. 

5—2 


68  SURGERY  OF  THE  STOMACH 

Tumour. — In  the  great  majorit}'  of  cases  of  cancer  of  the 
stomach  a  tumour  can  be  felt  at  some  period  of  the  disease. 
This  is  due  in  part  to  the  frequency  with  which  the  pyloric 
region  of  the  stomach  is  attacked,  and  in  part  to  the  fact  that 
the  presence  of  a  tumour  entails  a  certain  descent  of  the 
viscus,  which  brings  the  mass  into  the  field  of  palpation. 

It  is  of  the  first  importance  to  remember  that  the  presence 
of  a  tumour  is  evidence  of  large  and  late  involvement  of  the 
stomach.  It  has  been  said  by  Czerny  and  Rindfleisch  and 
by  Kraske  that  when  a  malignant  tumour  of  the  stomach 
can  be  felt  through  the  abdominal  wall,  the  growth  is  no 
longer  a  local  one,  and  is  therefore  unsuited  to  a  radical 
operation.  That  this  statement  is  not  rigidly  accurate  has 
been  proved  bj^the  experience  of  Kocher  and  other  surgeons, 
but  there  can  be  no  question  but  that  by  the  time  a  tumour  has 
developed  a  radical  operation  is  more  difficult,  attended  with 
a  greater  danger,  and  is  the  more  likely  to  be  followed  by  a 
speedy  recurrence.  The  endeavours  of  clinicians  now  and 
in  the  future  must  be  towards  the  perfecting  of  our  methods  of 
diagnosis  in  the  days  before  a  palpable  tumour  has  developed. 

Character  of  the  Tumour. — For  examination  of  the  abdomen 
the  patient  must  be  upon  the  back,  with  the  knees  slightly 
flexed.  The  abdomen  must  be  freely  uncovered  and  exposed 
to  a  good  light.  A  tumour,  if  of  large  size  or  if  projecting, 
can  occasionally  be  seen  on  inspection.  Deep  respiration 
will  cause  the  ascent  and  descent  of  the  tumour  to  the  extent, 
perhaps,  of  some  inches.  Lateral  movement  is  chiefly  noted 
in  cases  of  pyloric  tumour,  but  may  be  equally  present  when 
the  body  of  the  stomach  is  implicated.  The  position  of  the 
tumour  under  the  varying  degrees  of  artificial  distension  of 
the  stomach  should  be  studied,  and  will  give  useful  informa- 
tion. Complete  emptying  of  the  stomach  will  sometimes 
reveal  an  otherwise  impalpable  tumour.  As  the  growth 
enlarges  and  adhesions  form,  its  mobility  becomes  impeded, 
but  the  greater  or  lesser  range  of  the  movement  affords  no 
precise  indication  as  to  the  character  and  extent  of  the 
adhesions.  The  tumour  may  be  hard  and  smooth,  or 
irregularly  nodular,  and  may  seem,  when  situated  in  or  near 
the  pylorus,  to  vary  in  size.     The  apparent  sudden  increase 


CANCER  OF  THE  STOMACH  69 

is  probably  due  to  the  hardening  by  tonic  contraction  of  the 
hypertrophied  muscle  fibres  at  the  pyloric  antrum. 

Dilatation  of  the  stomach  is  the  inevitable  result  of 
narrowing  of  the  outlet.  According  to  Osier,  the  commonest 
cause  of  dilatation  of  the  stomach  is  malignant  disease  of  the 
pylorus.  The  extent  of  the  dilatation  is  determined  by  the 
narrowing  of  the  exit,  and  upon  the  duration  of  the  obstruc- 
tion. All  degrees  of  distension  are  met  with  ;  the  stomach 
may  even,  as  in  one  of  our  cases,  almost  fill  the  abdomen, 
and  descend  behind  the  pubes  into  the  true  pelvis.  Waves 
of  contraction  will  generally  be  seen   readily ;  they  may  be 


Fig.  19. — Extremely  Small  Stomach  with  Duodenal  Walls 
Dependent  on  Neoplasm — 'Leather-bottle  Stomach.' 

(No,  2,408,  Royal  College  of  Surgeons'  Museum.) 

elicited,  or,  if  sluggish,  increased  by  artificial  distension  of 
the  organ  with  carbonic  acid  gas.  Percussion  and  ausculta- 
tion give  little  information  of  value. 

In  about  half  the  cases  observed,  a  rise  of  temperature  of 
greater  or  less  range  will  be  noticed.  As  a  rule,  the  fever  is 
trivial  and  inconspicuous.  Deep  ulceration  of  the  growth 
with  pus  formation,  loculi  of  pus  lying  between  an  ulcer  on 
the  posterior  wall,  and  the  body  of  the  pancreas,  for  example, 
may  cause  chills  and  high  fever.  The  importance  of  enlarge- 
ment of  the  supraclavicular  glands,  as  positive  evidence  of 
carcinoma  of  the  stomach,  is  pointed  out  by  Riegel.  The 
gland  which  first  enlarges  is  situated  on  the  left  side  of  the 
neck  at  the  posterior  border  of  the  sterno-mastoid,  just  above 


70  SURGERY  OF  THE  STOMACH 

the  clavicle.  The  absence  of  glandular  enlargement  here  is, 
however,  void  of  significance.  Ascites  is  occasionally  present, 
and  may  be  of  such  grossness  as  to  mask  the  original  disease, 
Hampeln  and  Strauss  {Dent.  Med.  Woch.,  1901)  have  noticed 
the  frequency  with  which  pleural  effusion  on  the  left  side 
is  associated  with  carcinoma  of  the  stomach,  and  consider 
that  the  association  may  at  times  be  of  diagnostic  import. 
Jaundice,  oedema  of  the  legs,  thrombosis  of  one  or  many 
veins,  perforation  of  an  ulcerating  growth  followed  by  peri- 
tonitis, and  metastases  in  the  umbilicus,  abdominal  wall, 
ribs,  or  elsewhere,  are  signs  observed  in  the  last  days  of  the 
disease. 

The  Blood  in  Carcinoma  of  the  Stomach. 

The  blood,  as  a  rule,  shows  the  changes  found  in  secondary 
anaemia.  Beyond  this,  the  information  given  by  an  examina- 
tion is  of  doubtful  value.  Krokiewicz  states  that  there  is  no 
change  in  the  red  blood  corpuscles.  In  thirteen  cases  diges- 
tion leucocytosis  was  absent.  Krokiewicz  agrees  with  Lowitt 
that  this  sign  is  'of  equal  value  with  absence  of  HCl  and 
presence  of  lactic  acid.'  In  nearly  all  cases  the  alkalinity 
of  the  blood  was  lessened.  Osier  and  McCrae  come  to  the 
following  conclusions : 

1.  Neither  an  increase  in  the  leucocytes  nor  special  varia- 
tions in  the  forms  appears  to  be  of  any  moment  in  the 
diagnosis  of  cancer  of  the  stomach. 

2.  The  presence  or  absence  of  digestion  leucocytosis  is  too 
uncertain  to  be  of  much  assistance  in  diagnosis  (in  twenty- 
two  cases  was  present  in  ten,  absent  in  twelve). 

According  to  Lindner  and  Kuttner,  absence  of  digestion 
leucocytosis  is  noticed  rather  more  frequently  in  malignant 
than  in  simple  disease.  Hartmann  and  Silhol  {Rev.  de  Chir., 
1901,  No.  2)  have  recently  communicated  to  the  Societe  de 
Chirurgie  the  results  of  some  researches  made  on  the  blood 
of  surgical  patients.  In  the  course  of  these  researches  they 
have  become  convinced  that  in  cancer  of  the  stomach  an 
examination  of  the  blood  is  more  likely  to  prove  useful 
than  a  chemical  investigation  of  the  gastric  contents.  The 
authors    made    particular  investigations    on   two   questions : 


CANCER  OF  THE  STOMACH  71 

{a)  The  degree  of  anaemia  characterized  by  diminution  of 
the  quantity  of  haemoglobin,  which  may  depend  on  the 
reduction  of  the  number  of  globules  or  on  the  reduced  pro- 
portion of  haemoglobin  in  their  contents ;  and  (6)  the  exist- 
ence of  leucocytosis.  The  presence  of  cancer  of  the  stomach, 
it  is  held,  is  indicated  by  a  well-marked  association  of 
decided  anemia  with  decided  leucocytosis.  Anaemia  is 
marked  less  by  the  diminished  number  of  globules  than  by 
(i)  a  diminished  proportion  of  the  haemoglobin  in  the 
globules ;  (2)  by  irregularity  in  the  form  of  the  globules, 
indicating    a   profound    modification    of    the    elasticity    and 


P~iG.  20. — Colloid  Cancer  of  Pylorus  producing  Stenosis. 
(No.  2,426,  Royal  College  of  Surgeons'  Museum.) 

texture  of  the  red  globules ;  and  (3)  by  inequality  in  the  size 
of  those  globules  that  are  not  misshapen.  The  leucocytosis, 
to  have  any  value  as  a  symptomatic  sign,  should  be  very 
marked,  and  should  affect  especially  the  mono-nucleated 
cells. 

Examination  of  the  Stomach  Contents. 

In  all  cases  of  suspected  cancer  of  the  stomach,  the 
examination  of  the  contents  is  of  the  greatest  importance. 
From  such  examination,  information  is  afforded  upon  the 
following  points  : 

I.  The  motility  of  the  stomach. 


72  SURGERY  OF  THE  STOMACH 

2.  The  defective  secretion  of  the  gastric  juice,  as  mani- 

fested by  the  diminution  of  free  HCL 

3.  The  presence   of  adventitious  products,  the  resuh  of 

stagnation,    such   as    lactic    acid  and    the   Oppler- 
Boas  bacillus. 

4.  The  presence  of  fragments  of  growth. 

1.  The  Motility  of  the  Stomach  is  best  tested  by  the  examina- 
tion of  the  stomach  after  the  administration  of  Ewald's 
breakfast.  At  the  end  of  three,  or  at  the  most  four,  hours 
all  traces  of  this  meal  should  be  absent  from  the  stomach. 
If  any  be  found,  the  quantity  affords  a  rough  estimate  of 
the  impairment  of  the  motor  function  of  the  viscus.  Such 
impairment  may  be  due  to  stenosis  of  the  pylorus,  or  invasion 
of  the  wall  of  the  stomach  by  growth.  The  employment  of 
any  mechanical  appliance,  such  as  the  '  deglutable,  india- 
rubber  stomach-shaped  bag  '  of  Hemmeter,  is  unnecessary. 

The  motility,  according  to  Hemmeter,  who  has  devoted 
considerable  attention  to  the  subject,  is  chiefly  affected  in 
disease  of  the  orifices  of  the  stomach.  In  chronic  gastritis 
the  motility,  if  impaired,  is  less  so  than  in  cancer;  in  neuroses 
the  motility  is  increased. 

2.  Defective  Secretion  of  the  Gastric  Juice  was  first  observed 
by  Von  der  Velder  in  1 879.  The  contents  of  the  stomach  after 
the  administration  of  Ewald's  test-breakfast  are  examined. 
It  is  important  to  emphasize  the  fact  that  a  single  examina- 
tion of  this  kind  is  not  enough.  Repeated  examinations  are 
necessary  in  order  to  arrive  at  the  truth.  The  reliance  to 
be  placed  upon  chemical  examination  is  very  differently 
estimated  by  authors.  We  are  accustomed  to  consider  that, 
if  free  hydrochloric  acid  is  permanently  absent  and  lactic  acid 
is  present  in  a  patient  whose  symptoms  are  those  described 
above,  there  is  strong  presumption  in  favour  of  a  diagnosis 
of  malignant  disease.  In  a  series  of  343  cases  of  cancer 
recorded  by  Boas,  Hammerschlag,  Schneider,  Rosenheim, 
and  Osier,  897  per  cent,  showed  an  absence  of  free  HCl. 
It  will  be  seen  from  this,  however,  that  there  are  io"3  per 
cent,  of  cases  in  which  a  diagnosis  based  upon  this  point 
alone  would  be  misleading.  In  some  of  these  it  is  probable 
that  there  has  been  a  malignant  implantation  upon  a  simple 


■    CANCER  OF  THE  STOMACH  7^ 

ulcer.  It  is  recognised  as  a  well-established  fact,  to  which 
Rosenheim  first  called  attention,  that  in  such  cases  (ulcus 
carcinomatosum)  free  HCl  is  frequently  present,  sometimes  in 
excess.  Hemmeter  says:  'In  all  carcinomas  that  have  arisen 
from  ulcers,  free  HCl  in  normal,  or  even  in  increased, 
amounts  may  continue  until  death.'  In  others  the  carcinoma 
may  be  limited  to  a  small  area  at  the  pyloric  end,  where 
there  are  no  oxyntic  or  border  cells,  which  alone,  according 
to  Heidenhain  and  Mall,  are  concerned  in  the  production  of 
hydrochloric  acid.  (In  all  the  cases  recorded  by  Osier,  in 
which    HCl   was   present,    a   tumour   was    observed.)     The 


"^"^N 


Fig.  21.— Pyloric  Stenosis  from  Ulcer  with  Hypertrophy  of  Stomach. 
(No.  2,415,  Royal  College  of  Surgeons'  Museum.) 

changes  occurring  in  the  mucous  membrane  of  the  stomach 
in  cases  of  cancer,  and  determining  the  alteration  in  the 
secretion,  are  described  as  {a)  simple  catarrhal  inflammation, 
(&)  interstitial  gastritis,  and  (c)  atrophy  of  the  glands. 
Hammerschlag  quotes  certain  cases  in  which  the  histological 
condition  could  be  compared  with  the  chemical  findings  : 
'  It  was  found  that  in  cases  of  carcinoma  in  which  hydro- 
chloric acid  was  present  there  were  very  slight,  or  no, 
changes  in  the  mucous  membrane.  But  in  cases  where  the 
HCl  and  the  ferments  were  absent  and  lactic  acid  present 
there  was  found  atrophy  of  the  specific  gland  elements,  and 
substitution  by  cylindrical  epithelium  or  fibrous  connective 
tissue.'     This  atrophy  will  account  also  for  the  diminished 


74  SURGERY  OF  THE  STOMACH 

and  delayed  absorption  pointed  out  b}'  Eichhorst,  Zweifel, 
and  others.  In  a  condition  of  health,  the  iodine  reaction 
should  be  obtained  from  the  saliva  a  quarter  of  an  hour  after 
the  administration  of  a  cachet  of  5  grains  of  potassium  iodide. 
In  carcinoma  the  reaction  may  be  delayed  an  hour  or  more. 

3.  The  Presence  of  Adventitious  Substances — Lactic  Acid. — The 
discussion  as  to  the  precise  significance  to  be  attached  to  the 
presence  of  lactic  acid  in  the  stomach  contents  has  been 
given  a  considerable  prominence  in  medical  journalism  in 
recent  years.  Lactic  acid  is  either  introduced  into  the 
stomach  as  such,  in  small  quantities,  or  is  formed  by 
abnormal  fermentative  processes.  It  is  evidence  of  gastric 
stagnation  and  impairment  of  the  motor  capacity,  and  is 
associated  with  a  reduction  in  the  amount  of  the  digestive 
ferments.  In  order  to  test  for  it,  a  special  meal,  Boas's 
oatmeal  and  water  breakfast,  must  be  given,  after  carefully 
washing  out  the  stomach.  Uffelmann's  test  is  employed 
(see  p.  17). 

In  268  cases  of  cancer  quoted  by  Schiff,  lactic  acid  was 
found  in  197  cases  =  73*5  per  cent.  Osier,  in  y2>  cases,  found 
lactic  acid  in  55  =  75*3  per  cent.  The  presence  of  lactic  acid 
is,  therefore,  evidence  of  some  value.  Its  absence,  however, 
cannot  be  held  to  be  of  any  significance.  Unfortunately, 
though  so  frequently  present  in  cancer,  it  is  not  found  at  an 
early  stage,  and  its  clinical  importance  is  therefore  diminished. 

The  value  of  the  chemical  findings  may  be  expressed  in 
this  manner  : 

If  HCl  is  permanently  absent,  and  lactic  acid  present,  the 
evidence  in  favour  of  cancer  is  strong. 

If  HCl  is  permanently  absent,  and  lactic  acid  is  absent, 
the  evidence  is  in  favour  of  cancer. 

If  HCl  is  present,  and  lactic  acid  is  present,  the  evidence 
is  against  malignant  disease,  though  the  possibility  of  ulcus 
carcinomatosum  should  be  borne  in  mind. 

The  Oppler-Boas  bacillus — a  long,  non-motile  bacillus  '  of 
the  shape  of  a  base-ball  bat.'  In  twenty  cases  of  malignant 
disease  of  the  stomach  recorded  by  Kaufmann,  the  bacilli 
were  present  in  large  numbers  in  nineteen.  In  sixteen 
recorded    by    Hemmeter,    they    were    present    in    fourteen. 


CANCER  OF  THE  STOMACH  75 

According  to  Schlesinger  and  Kaufmann  {Wicn.  Klin.  Riinds., 
1895,  No,  15),  '  the  presence  of  a  large  number  of  these  bacilH 
in  the  stomach  contents  is  an  indication  of  carcinoma.'  This 
observation  is  supported  by  Riegel.  Further  investigation  is 
required  before  an  opinion  of  worth  can  be  expressed,  but  it 
would  seem  as  though  the  presence  of  these  bacilli  is  of  the 
same  value,  as  an  evidence  of  cancer,  as  the  presence  of 
lactic  acid.  Their  absence  does  not  prejudice  the  diagnosis 
in  any  way.  Kaufmann  states  that  the  bacilli  are  capable  of 
forming  lactic  acid  from  sugar. 

4.  The  Presence  of  Fragments  of  Growth. — Various  means 
are  described,  and  by  some  surgeons  employed,  for  the 
purpose  of  obtaining  fragments  of  growth  from  the  stomach 
for  microscopical  investigation.  Efforts  in  this  direction  are 
to  be  deprecated.  Purposeful  attempts  to  scrape  or  brush 
away  portions  of  growth  are  not  devoid  of  danger.  Hem- 
meter  uses  an  indiarubber  stomach-tube,  with  a  sharpened 
edge  to  the  eye.  This  is  moved  slowly  backwards  and 
forwards  in  the  stomach.  A  fragment  of  growth  may  in 
that  way  be  caught  in  the  opening.  After  ordinary  lavage 
of  the  stomach,  the  tube  should  always  be  compressed 
duTing  withdrawal,  and  any  fragments  in  the  tube  carefully 
examined.  If  a  particle  of  growth  is  thereby  discovered,  the 
diagnosis  is  complete.  It  is  not  likely  that  such  a  fragment 
will  be  spontaneously  or  by  artifice  detached  from  the  growth 
in  the  earlier  stages,  when  its  discovery  would  be  most 
helpful. 

Diagnosis. 

It  cannot  be  too  often  repeated  nor  too  strenuously 
emphasized  that  cases  of  cancer  of  the  stomach  should 
be  dealt  with  surgically  at  the  earliest  possible  moment. 
The  evidence  to  which  we  have  alluded  certainly  goes  to 
show  that  for  some  length  of  time  the  disease  is  a  purely 
local  one.  In  the  surgery  of  the  breast,  the  tongue,  the 
uterus,  and  other  organs,  a  vast  improvement  has  been 
accomplished  since  early  diagnoses  (of  '  precancerous '  con- 
ditions) were  followed  by  early  and  extensive  operations. 
In  cases  of  cancer  of  the  stomach   a  like,  if  not  an  equal, 


76  SURGERY  OF  THE  STOMACH 

improvement  should  be  forthcoming.  It  is  therefore  neces- 
sary that  the  very  earliest  beginnings  of  malignant  disease  of 
this  organ  should  be  exhaustively  and  persistently  investi- 
gated. Whenever  a  patient  over  forty  years  of  age  complains, 
somewhat  suddenly,  of  indefinite  symptoms  of  gastric  uneasi- 
ness, pain,  and  vomiting,  followed  by  progressive  loss  of 
weight,  secondary  anaemia,  and  so  forth,  the  possibility  of 
cancer  should  at  once  be  recognised.  As  Osier  has  said, 
*  If  we  hear  that  a  woman  of  a  certain  age  complains  of 
a  bloody  discharge  from  the  uterus,  the  possibility  of 
malignant  disease  is  at  once  thought  of ;  but  how  many  of 
us  consider  a  like  grave  possibility  when  a  patient  of  the 
same  age  complains  of  stomach  symptoms,  perhaps  with  a 
moderately  sudden  onset.'  As  our  knowledge  stands  at 
present,  we  cannot  but  recognise  that  our  only  sure  method 
of  making  the  diagnosis  in  an  early  stage  is  by  an  exploratory 
operation.  Although  the  chemical  examination  of  the  stomach 
contents  and  the  general  examination  of  the  patient  may  give 
us  a  very  strong  impression  that  cancer  is  present,  our  diag- 
nosis can  only  be  rendered  certain  by  (i)  the  discovery  of 
fragments  of  growth  in  the  stomach  or  in  the  evacuated 
contents  (probably  a  late  sign),  or  (2)  the  digital  exploration 
of  the  organ  through  an  abdominal  incision  (the  '  lesser 
abdominal  section'  of  Mikulicz).  Such  a  digital  exploration 
by  a  competent  surgeon  is  devoid  of  risk,  and  may,  if  neces- 
sary, be  performed  (as  we  have  frequently  performed  gastros- 
tomy) under  cocaine  anaesthesia.  We  feel,  therefore, 
compelled  very  strongly  to  advocate,  in  all  cases  where 
there  is  any  doubt,  an  early  exploratory  operation.  In 
thus  advising,  we  would  still  impress  upon  both  physicians 
and  surgeons  the  urgent  need  of  the  most  painstaking  and 
the  fullest  examination,  in  the  hope  that  some  result  from 
their  labours  may,  by  establishing  a  criterion,  thereby  do 
away  with  the  need  of  an  '  exploratory '  incision.  Though 
such  careful  investigation  is  absolutely  essential,  it  should 
not  be  unduly  prolonged.  To  await  the  development  of  a 
'  tumour '  before  consenting  to  a  diagnosis  of  malignant 
disease  and  advising  operation  is  to  prove  one's  self  in 
ignorance  of  the  real  issues  at  stake.     Cancer  of  the  stomach 


CANCER  OF  THE  STOMACH 


77 


should  he  dealt  with  surgically  before  a  tumour  is  clinically 
recognisable.  In  this  alone  lies  our  hope  for  successful 
treatment,  and  it  may  be  also  our  means  of  establishing 
an  early  diagnosis. 

In  the  recent  admirable  work  on  '  Cancer  of  the  Stomach  " 
by  Osier  and  McCrae,  the  following  statements  are  made  : 
'  The  important  aid  of   an  exploratory  operation  should  be 


Fig.  22. — Perforation  of  the  Stomach  due  to  Sloughing  Cancer. 
(No.  2,407,  Royal  College  of  Surgeons'  Museum.) 

more  frequently  advised.'  '  The  risk  is  comparatively  slight, 
and  is  much  less  than  that  of  an  undiagnosed  neoplasm.' 
'  In  a  suspected  case,  when  under  treatment  there  is  no  im- 
provement in  a  few  weeks,  an  exploratory  operation  is  justifi- 
able.' 

The  exploratory  examination,  however,  does  not  give 
information  which  is  infallible.  Several  observers,  Czerny, 
Mayo    Robson,    and    others,    have    recorded     cases    where 


78  SUJ^GERY  OF  THE  STOMACH 

malignant  disease  was  diagnosed,  in  which  the  event  proved 
the  tumour  to  have  been  simple  inflammatory  thickening 
round  a  chronic  ulcer.  Such  cases,  however,  are  excep- 
tional, and  only  afford  additional  support  to  our  advocacy 
of  the  earliest  possible  exploration. 

The  Choice  of  Operation  in  Cancer  of  the  Stomach. 

I.  In  Pyloric  Cancer. — Surgeons  of  some  experience  in 
operations  upon  the  stomach  are  divided  in  their  opinions 
as  to  the  better  operation  in  cases  of  malignant  disease  of 
the  pylorus.  On  the  one  hand  are  those  who,  believing  that 
a  diagnosis  of  malignant  disease  cannot  be  made  while  yet 
the  disease  is  local,  advocate  a  palliative  operation,  gastro- 
enterostomy, with  the  idea  of  giving  rest  to  the  diseased 
area,  and  thereby  retarding  growth,  as  in  colotomy  for 
malignant  disease  of  the  rectum.  On  the  other  hand  are 
those  who,  having  been  tempted  to  employ  a  radical  opera- 
tion in  some  favourable  case  or  series  of  cases,  are  so 
impressed  with  its  advantages  that  they  become  apostles 
of  a  broader  creed,  and  advocate  local  extirpation.  Our 
opinion  emphatically  is  that  in  all  cases,  whenever  possible,  a 
radical  operation  should  he  attempted.  Under  present  conditions 
of  diagnosis,  the  probability  is  that,  when  a  patient  is  sub- 
mitted to  operation,  gastro-enterostomy  is,  in  general,  a  safer 
operation  than  pylorectomy.  But  although  the  comfort  and 
sense  of  well-being  of  the  patient  may  improve  very  decidedly 
for  a  time  after  the  former  operation,  the  tumour  is  still 
slowly  enlarging  in  size,  and  will  eventually  cause  death. 
How  much  of  the  general  ill-health,  cachexia,  and  so  forth, 
are  induced  by  absorption  from  the  growth,  by  necrotic 
changes  in  its  mass,  by  ulceration  and  haemorrhages  upon 
the  surface,  is  quite  unknown,  but  one  may  presume  that 
such  influences  are  not  trivial.  Krokiewicz  and  Pilliet 
believe,  indeed,  that  cancer  cachexia  is  the  result  of  in- 
toxication with  the  by-products  of  metabolism  of  the  cancer 
cells.  A  local  extirpation,  then,  even  if  followed  by  a  recur- 
rence, will  probably  prolong  life  for  a  greater  period  and  in 
greater  comfort  than  a  gastro-enterostomy.  It  was  doubtless 
an  opinion  similar  to  this  which  led  Terrier  to  remark  that 


CANCER  OF  THE  STOMACH  79 

'  the  best  form  of  gastro-enterostomy  was  done  after  re- 
moval of  the  pylorus.'  But  increasing  experience  in  the 
most  competent  hands  all  tends  to  show  that  in  properly- 
selected  cases  pylorectomy  is  not  an  operation  of  very  grave 
risk,  and  is  an  operation  of  generous  promise. 

We  very  much  doubt  whether  the  discussion  of  this 
question  is  materially  helped  by  any  reference  to  statistics. 
The  contrast  in  tabular  form  of  the  mortality  of  gastro- 
enterostomy and  partial  gastrectomy  is  most  futile  and  mis- 
leading. To  show  how  absurd  this  fettering  of  our  practice 
to  statistics  may  be,  we  may  quote  the  figures  of  Carle  and 
Fantino,  who  have  an  operation  mortality  of  about  40  per 
cent,  in  gastro-enterostomy,  and  of  20  per  cent,  in  pylorec- 
tomy. Wolfler  tabulated  2ig  cases  of  operation  for  cancer 
performed  between  the  years  1888  and  1896.  The  death- 
rate  in  cases  of  gastro-enterostomy  was  36  per  cent.,  in 
pylorectomy  3i"2  per  cent.  The  rate  of  mortality  must  be 
very  largely  a  question  of  the  age  and  condition  of  the 
patient  and  the  duration  and  stage  of  the  disease.  In  an 
early  case  of  p3'loric  cancer,  gastro-enterostomy  has  a  small 
mortality — perhaps  approaching  in  insignificance  the  mor- 
tality in  cases  of  simple  stenosis ;  in  moderately  advanced 
or  late  stages  the  mortality  is  very  large. 

Partial  gastrectomy  in  the  early  days  of  its  employment 
was  an  exceedingly  serious  operation,  with  an  appalling 
death-rate.  Latterly  the  mortality  is  seen  to  be  a  gradually, 
but  persistently,  diminishing  one.  In  comparing  and  con- 
trasting the  two  operations,  we  may  refer  to  the  following 
points  : 

(a)  The  prolongation  of  life. 

{h)  The  general  condition  of  the  patient  subsequently. 
{a)  The  Prolongation  of  Life. — Kronlein  has  calculated  that 
a  patient  suffering  from  gastric  cancer,  still  operable,  but 
not  submitted  to  resection,  will  live  209  days.  This  is  less 
by  at  least  a  year  than  the  average  duration  of  life  after 
resection.  Moreover,  after  resection  there  is  always  the 
chance — a  slender  one,  perhaps,  but  still  a  chance — of  a 
permanent  cure.  The  following  list  of  cases  will  show  that 
a  long  existence  after  resection  is  not  so  rare  as  is  supposed : 


8o  SURGERY  OF  THE  STOMACH 

Wolfler  {Bcrl.  Klin.  Wochcnsch.,  1896),  after  personal  inquiry, 
had  records  of  fourteen  cases  who  were  alive  or  had  lived 
over  two  \-ears  ;  of  three  (Czern}',  Hahn,  Gersuny)  who  had 
lived  more  than  four  years  ;  of  four  (Billroth,  Kocher,  Maydl, 
Wolfler)  who  had  lived  more  than  five  3'ears  ;  of  one  case 
of  sarcoma  alive  after  six  3-ears  :  and  of  two  (Kocher,  Rati- 
moff)  alive  after  eight  years.  To  these  Guinard  {These  de 
Paris,  1898)  adds  one  case  (Montaz)  alive  after  two  years  ; 
one  case  (Lauenstein)  alive  after  two  years  ;  one  case  (Peug- 
niez)  alive  after  four  years ;  one  case  (Carle)  alive  after  five 
years ;  and  three  (Schuchardt,  Funke,  Hochenegg)  who  had 
lived  between  two  and  three  years.  At  the  Deutsch.  Gesellsch. 
f.  Chir.,  1898-  Kronlein  recorded  two  cases  alive  and  well 
after  four  years ;  Czerny,  three  cases  after  two  and  a  half, 
seven,  and  eight  years  (the  last  the  case  of  sarcoma  above 
referred  to)  ;  Lobker,  two  cases  after  five  and  seven  years ; 
Hahn,  one  case  after  seven  and  one  case  after  four  years  ; 
and  Hacker,  one  case  after  six  years,  and  a  case  of  Billroth's 
after  eight  years.  Jessop  has  one  patient  still  living  after  a 
pylorectomy  performed  for  malignant  disease  on  Decem- 
ber 28,  i8gi.  Such  a  list  is  most  encouraging.  The  pro- 
longation of  life,  however,  is  not  the  sole  advantage  accruing 
from  the  more  radical  measure.  The  greater  comfort,  the 
brighter  health,  the  better  nutrition,  are  the  all-important 
benefits.  As  Mikulicz  says  :  '  If  we  do  not  prolong  life  by  a 
single  day,  the  operation  is  still  justified  in  my  eyes.'  The 
compensations,  therefore,  for  the  greater  risk  run  in  the 
more  severe  operation  are  the  increased  prolongation  of  life 
and  the  greater  comfort  of  the  lengthened  days. 

(b)  The  General  Condition  of  the  Patient  subsequent  to  Opera- 
tion is  without  question  in  all  respects  better  after  gastrec- 
tomy, especially  after  end-to-end  suture.  For,  in  the  first 
place,  the  absorption  of  the  by-products  of  metabolism  in 
the  tumour  is  altogether  done  away  with  ;  and,  in  the  second, 
both  gastric  and  intestinal  digestion  and  absorption  are  less 
disturbed.  ]\Iintz  (quoted  by  Guinard)  has  shown  that,  what- 
ever the  condition  of  the  gastric  juice  may  have  been  previous 
to  operation,  after  gastro-enterostomy  the  secretion  rapidly 
diminishes,  and  finally  ceases,  and  after  gastrectomy  remains 


CANCER  OF  THE  STOMACH  8i 

in  the  same  quantity  and  condition  as  before  the  operation, 
Joslin  (Berl.  Klin.  Wochensch.,  1897),  working  under  the 
direction  of  Ewald,  found  that  after  gastro-enterostomy  the 
intestinal  absorption  of  albumin  was  but  little  modified,  but 
that  the  absorption  of  fats  and  hydrocarbons  was  consider- 
ably diminished.  Heinscheimer  {Mitt,  aus  den  Grenzgeheit. 
der  Med.  und  Chir.,  1896)  attributes  this  marked  loss  of  the 
power  of  absorption  to  the  cutting  off  of  the  duodenal  loop. 
Under  normal  conditions,  the  chyme  passing  into  the  duo- 
denum, a  portion  of  the  canal  where  the  intestinal  circula- 
tion is  languid,  has  ample  time  to  mix  thoroughly  with  the 
bile  and  pancreatic  juice,  and  is  thereby  rendered  more  easy 
of  absorption.  Hartmann  and  Soupault  {Rev.  de  Chinirgie, 
vol.  xix.)  state  that  after  gastro-enterostomy  patients  never 
recover  their  former  health  and  vigour. 

The  observations  of  Joslin  and  Heinscheimer  constitute 
important  arguments  in  favour  of  end-to-end  approximation 
after  removal  of  portions  of  the  stomach.  Of  the  methods 
in  vogue,  two — Kocher's  and  Mayo  Robson's  (bone  bobbin)  — 
are,  we  think,  the  best. 

There  are  certain  cases  where  the  argument  against 
pylorectomy  may  be  considered  to  be  valid.     These  are : 

{a)  Cases  in  which  extensive  and  extremely  dense  ad- 
hesions (to  liver,  pancreas,  gall-bladder,  etc.)  are 
present. 

(b)  Cases  in  which  a  widespread  enlargement  of  lym- 

phatic glands  is  found. 

(c)  Cases  in  which  secondary  deposits  in  the  liver  or 

elsewhere  are  seen. 

(a)  Adhesions  interfere  with  the  success  of  a  radical  opera- 
tion in  two  ways  :  They  increase  the  physical  difficulties  of 
the  operation ;  and,  being  channels  along  which  infection 
drifts,  they  are  presumptive  evidence  of  widespread  disease. 

{b)  Widespread  enlargement  of  glands,  if  mahgnant  in 
character,  forbids  local  extirpation  of  a  gastric  growth.  If 
the  glands  along  the  curvatures  of  the  stomach  in  the  greater 
and  lesser  omenta  are  alone  involved,  they  may  be  success- 
fully removed  at  the  same  time  as  the  growth.  Kader,  in 
eight   gastrectomies,    found   the   chief  enlargement    of    the 

6 


82  SURGERY  OF  THE  STOMACH 

glands  in  the  omentum,  below  the  pylorus.  When  the 
glands  at  the  head  of  the  pancreas  are  widely  involved,  any 
attempt  at  their  removal  is  dangerous,  and  almost  neces- 
sarily incomplete.  An  enlargement,  however,  is  not  neces- 
sarily malignant.  Many  observers  have  noticed  in  this 
region,  as  in  the  breast  (Halsted),  a  simple  inflammatory 
enlargement  of  glands,  in  association  with  malignant  disease 
of  the  tributary  area.  Malignant  glands  are  generally  much 
harder  than  the  inflammatory. 

(c)  Before  undertaking  any  operation  involving  local 
removal  of  growth,  a  very  careful  examination  should  be 
made  for  secondary  growths.  Small  button-shaped  nodules 
may  be  felt  on  the  upper  surface  of  the  liver  when  the  pyloric 
growth  is  hardly  bigger  than  a  signet-ring.  When  such 
secondary  growths  are  present  a  radical  operation  is  futile. 

2.  In  Mural  Cancer. — The  same  remarks  apply  to  cancer  of 
the  wall  of  the  stomach.  In  such  cases  obstruction  may  be 
absent.  Diagnosis  is  therefore  not  so  early,  so  that  when 
the  abdomen  is  opened  a  large  area  of  stomach  may  already 
be  affected.  Even  if  no  narrowing  is  produced,  a  gastro- 
enterostomy, by  determining  rest,  will  assuage  pain  and 
lessen  the  rate  of  growth.  A  complete  local  removal,  how- 
ever, is  the  ideal  for  whose  attainment  we  should  strive. 
The  extent  of  such  removal  will  vary  from  the  minimum  of 
an  hour-glass  stomach  to  the  maximum  of  a  general  infiltra- 
tion of  both  walls.  The  surgeon  will  be  guided  in  a  decision 
by  the  extent  of  such  growth  and  by  his  personal  capacity 
and  preference.  It  is,  we  think,  possibly  open  to  question 
whether  a  complete  gastrectomy  is  a  scientific  operation  or 
a  brilliant  exploit  in  surgical  gymnastics.  The  records  of 
the  cases  so  far  performed  are  certainly  far  better  than  could 
have  been  anticipated. 

In  all  cases  of  local  excision,  whether  in  the  body  of  the 
stomach  or  at  the  pylorus,  a  wide  healthy  area  surrounding 
the  growth  should  be  removed.  Experience  goes  forcibly  to 
show  that  it  is  from  local  recurrence  that  patients  die,  even 
when  the  incisions  have  been  made,  as  it  would  seem,  wide 
of  the  disease.  The  direction  of  the  spread  of  the  growth 
should   be   carefully  noticed.      If  the  growth  is   spreading 


CANCER  OF  THE  STOMACH  83 

circularly,  in  the  line  of  the  vessels,  it  shows  little  tendency 
to  recur  after  removal ;  if  it  is  spreading  transversely  along 
the  curvatures,  there  is  said  to  be  a  strong  tendency  to  recur- 
rence (Mayo).  The  importance  of  Cuneo's  observations, 
already  referred  to  (p.  62),  may  be  again  emphasized. 

3.  In  Growth  at  the  Cardiac  End. — Only  palliative  opera- 
tions are  possible  when  the  growth  involves  the  cardiac 
orifice  and  the  adjacent  portion  of  the  stomach.  Levy  has, 
indeed,  planned  an  operation,  and  practised  it  upon  the 
cadaver,  for  the  purpose  of  removing  such  a  growth  {Langen- 
beck  Archiv.,  i8g8),  but,  so  far  as  we  know,  a  procedure  of 
this  kind  has  only  once  been  attempted  during  life. 

This  was  by  Mikulicz,  who  removed  a  primary  carcinoma 
of  the  cardia  and  a  portion  of  the  oesophagus  between 
3  and  4  centimetres  in  length.  The  operation  was  exceed- 
ingly difficult  on  account  of  spreading  of  the  growth  towards 
the  pancreas  and  implication  of  the  retroperitoneal  13/mphatic 
glands.  The  patient  died  of  peritonitis.  Mikulicz  expresses 
the  hope  that  not  only  carcinoma  of  the  cardia,  but  even  of 
the  lower  end  of  the  oesophagus,  may  prove  within  the  safe 
reach  of  a  capable  surgeon. 

Krehl  has  shown  that  in  dogs  the  two  pneumogastrics 
may  be  completely  destroyed  at  the  lower  end  of  the  oeso- 
phagus without  interfering  in  any  degree  with  the  processes 
of  digestion. 

In  all  cases,  gastrostomy  should  be  performed  at  the  earliest 
moment  after  the  diagnosis  is  assured. 


6—2 


CHAPTER  VI 

SARCOMA  OF    THE    STOMACH 

Sarcoma  of  the  stomach  may  be  primary  or  secondary.  The 
former  is  the  more  frequent,  and  alone  is  of  interest  to  the 
surgeon.  Primary  sarcoma  was  formerly  considered  an  ex- 
tremely rare  disease — a  pathological  curiosity,  in  fact ;  but 
recent  observation  makes  it  probable  that  not  a  few  cases  of 
so-called  '  cancer  '  are  in  reality  examples  of  true  sarcoma. 
Perry  and  Shaw,  in  their  well-known  paper  (Guy's  Hospital 
Report,  1892),  found  that  four  of  fifty  museum  specimens  of 
malignant  disease  of  this  organ  were  sarcomata.  Schlesinger 
(Zeitsch.  f.  Klin.  Med.,  1897)  collected  the  records  of  thirty 
cases.  Fenwick,  in  November,  1900  {Lancet),  makes  mention 
of  sixty,  and  of  these  fifty-three  were  recorded  at  sufficient 
length  to  permit  of  analysis  and  classification. 

The  following  pathological  varieties  are  recognised  : 
I.  Round-celled  Sarcoma  ('Lympho-sarcoma '). — Thirty-three 
of  the  fifty-three  are  of  this  form.  The  tumour  is  generally 
found  in  the  pyloric  portion  of  the  stomach,  giving  rise  to  a 
considerable  local  thickening  and  induration,  which  shades 
off  into  tough  bands  along  the  curvatures.  The  growth  may 
project  boldly  upon  the  surface,  or  may  form  a  solid  stiff 
plate  in  the  thickness  of  the  stomach  wall.  The  pyloric 
orifice  is  not  narrowed,  but  as  a  rule,  according  to  Fenwick, 
the  rigidity  of  its  tissues  renders  it  patent,  and  the  valve  in- 
competent rather  than  contracted.  The  disease  commences 
in  the  submucosa,  and  extends  to  the  muscular  coat ;  the 
mucosa  is  stretched  by  the  growth,  thinned,  and  at  times 
ulcerated.  It  has  been  shown  (Redtenbacher, /aAr6«cA  der 
Wiener  Krankenaustalten,   1894)  that  a  diffuse  infiltration  of 


SAJ^COMA  OF  THE  STOMACH  85 

round  cells  in  the  mucosa  extends  some  distance  beyond  the 
obvious  limits  of  the  disease. 

The  following  are  typical  cases  recorded  in  the  literature : 
Hadden  (Pathological  Society's  Transactions,  vol.  xxxvii., 
1886)  describes  a  case  of  lympho-sarcoma  of  the  stomach. 
There  was  '  a  globular  tumour  in  the  anterior  wall  of  the 
stomach,  close  to  the  lesser  curvature,  rather  nearer  the 
pyloric  orifice  than  the  cardiac  orifice.  On  the  inner  surface 
of  the  stomach,  corresponding  to  the  mass  seen  externally,  a 
triangular  ulcer,  if  inches  in  its  largest  measurement,  was 
found.  The  ulcer  led  by  a  free  opening  into  the  centre  of 
the  tumour  for  a  distance  of  i  J  inches.  This  excavation  was 
roughly  globular,  and  its  external  surface  fairly  smooth.  On 
microscopic  examination,  the  tumour  w^as  found  to  be  com- 
posed of  small  round  nucleated  cells  contained  in  a  reticular 
stroma.  In  fact,  the  growth  seemed  to  be  a  lympho-sarcoma, 
but  its  peculiarities  consisted  in  a  papillary  or  alveolar 
arrangement ;  and  in  the  centre  of  most  of  these  alveoli  a 
small  vessel  could  be  seen.'  This  case  illustrates  the  tendency 
of  these  growths  to  soften,  ulcerate,  and  break  down. 

S chop/ (Cent.  f.  Chir.,  1899,  p.  1163). — In  this  female  patient 
there  was  a  large  movable  tumour  of  the  size  of  a  child's 
head  in  the  abdomen.  The  abdomen  was  opened,  numerous 
glands  found  in  the  small  and  large  omenta,  and  a  tumour 
occupying  the  greater  part  of  the  stomach.  The  stomach 
was  removed  two  fingers'  breadth  from  the  cardia,  and  one 
from  the  pylorus,  and  the  cut  ends  of  viscus  stitched  together. 
The  tumour  was  seen  on  examination  to  occupy  the  lower 
two-thirds  of  the  portion  of  stomach  removed,  was  hard  and 
nodular,  and  microscopically  was  lympho-sarcoma.  The 
patient  recovered  from  the  operation,  and  was  well  without 
recurrence  twelve  months  later. 

Finlayson  (British  Medical  Journal,  vol.  ii.,  1899,  p.  1535) 
records  an  example  of  round-celled  sarcoma  in  a  boy  three 
and  a  half  years  old.  The  tumour  was  not  diagnosed  during 
life.  The  chief  symptom  was  a  profound  anaemia.  There 
was  a  slight  but  continuous  pyrexia.  The  child  sank  gradu- 
ally, and  died,  the  growth  being  found  post-mortem. 

2.  Spindle-celled  Sarcoma. — Twelve  of  the  fifty-three  are  of 


86  SURGERY  OF  THE  STOMACH 

this  variety.  This  form  of  growth  is  generally  seen  as  a 
circumscribed  tumour  near  the  greater  curvature  of  the 
stomach  ;  it  is  often  pedunculated,  and  when  growing  on  the 
posterior  surface  hangs  in,  and  by  its  enlarging  may  obliterate, 
the  lesser  sac  of  the  peritoneum.  The  larger  the  mass 
formed,  the  softer,  as  a  rule,  is  the  tissue  composing  it. 
Cystic  or  gelatinous  degeneration  is  not  seldom  observed. 
The  following  are  examples  : 

Billroth  successfully  removed  a  cystic  sarcoma  attached  to 
the  greater  curvature  and  the  contiguous  portions  of  the 
anterior  and  posterior  walls. 

Hartley  {Annals  of  Surgery,  vol.  xxiii.,  i8g6,  p.  6og). — The 
tumour  occurred  in  a  woman  fifty-four  years  of  age.  Except 
for  long-standing  dyspepsia,  she  had  been  in  perfect  health 
until  five  years  before.  At  that  time  she,  without  apparent 
cause,  vomited  a  large  amount  of  '  coffee-ground  '  material. 
For  four  years  she  remained  without  symptoms,  then  had 
another  attack  of  vomiting  of  coffee-ground  material  and  blood 
and  clots.  Pain  in  the  back  was  now  complained  of,  and 
a  tumour  was  noticed  in  the  epigastrium.  On  physical  ex- 
amination, there  was  felt  in  the  left  lumbar  and  umbilical 
regions  a  rounded  tumour,  hard,  elastic,  freely  movable.  A 
tentative  diagnosis  of  movable  kidney  was  made,  but  was, 
when  the  patient  was  examined  under  ether,  considered 
doubtful.  An  incision  was  made  in  the  left  linea  semilunaris, 
and  the  tumour  was  felt  behind  the  transverse  mesocolon  in 
the  left  splenic  region.  The  mesocolon  was  torn  through, 
and  the  tumour  exposed,  lying  in  the  lesser  sac.  The  growth 
was  seen  to  spring  from  the  posterior  wall  of  the  stomach  by 
a  pedicle  i-i  inches  in  diameter.  The  stomach  w^as  pulled  well 
forwards,  grasped  below  the  pedicle  ;  its  wall  was  cut  through 
entirely  around  the  pedicle,  removing  a  portion  of  its  wall 
with  the  tumour.  The  stomach  opening  was  closed.  The 
pathological  report  was :  *  Pear-shaped  tumour  15x10x8 
centimetres.  Its  surface  is  smooth,  but  nodular.  The 
tumour  is  cystic.  An  area  of  stomach  wall  5x4  centimetres 
has  been  removed  with  the  tumour.  Sections  of  the  tumour 
show  the  typical  appearance  of  spindle-celled  sarcoma.' 

Cantwell  {Annals  of  Surgery,  vol.  ii.,  i8gg,  p.  5g6). — A  female 


sai^cOjIia  of  the  stomach  87 

patient,  aged  fifty-two,  complained  of  a  large  abdominal 
tumour  presenting  no  signs  or  symptoms  save  those  of  weight 
and  pressure.  On  opening  the  abdomen,  an  immense  mass, 
covered  by  omentum  and  mesentery,  presented.  An  opening 
was  made  through  its  envelopes  down  to  the  tumour  proper, 
which  was  so  soft  as  to  verge  on  the  gelatinous  ;  from  its 
whole  surface  there  oozed  bloody  serum.  It  was  not  until 
the  tumour  was  carefully  enucleated  and  lifted  from  its  bed 
that  it  was  seen  to  arise  from  the  posterior  wall  of  the  stomach 
down  to  its  greater  curvature.  The  weight  had  dragged  the 
stomach  down  to  a  point  several  inches  lower  than  its 
ordinary  "position.  The  growth  with  part  of  the  stomach 
was  cut  away  with  scissors,  and  the  wound  closed  with  two 
tiers  of  sutures.  On  the  tenth  day  a  parotitis  occurred,  as 
in  Christy  Wilson's  case,  but  subsided.  The  tumour  weighed 
12  pounds,  and  5  inches  square  of  the  mucous  membrane  of 
the  stomach  had  to  be  removed.  Recurrence  was  noticed 
eight  months  after  operation. 

3  and  4.  Myosarcoma  (five  cases  of  the  fifty-three)  and 
Angiosarcoma  (two  of  the  fifty-three)  are  unusual  varieties. 
The  former  are  characterized  by  a  remarkable  tendency  to 
extravagant  haemorrhage,  which  imperils  the  patient's  life. 
An  example  of  the  latter  was  successfully  removed  by  Kosinski 
{Deutsch.  Gescllsch.  f.  Chir.,  1892). 

All  these  varieties  exhibit  a  marked  proneness  to  the 
formation  of  metastatic  deposits  in  the  skin  or  elsewhere.  A 
small  nodule  has  been  on  several  occasions  noticed  at  the 
umbilicus.  An  example  of  melanotic  sarcoma,  with  deposits 
in  the  skin,  is  preserved  in  the  Hunterian  Museum  at  the 
Royal  College  of  Surgeons ;  the  visceral  deposit  is  probably 
secondary. 

Symptoms. 

The  symptoms  of  sarcoma  very  closely  resemble  those  of 
carcinoma.  One  of  the  earliest  and  most  striking  features  is 
a  progressive  emaciation  with  failure  of  physical  power. 
Anaemia  is  almost  constant,  and  is  often  profound,  suggesting 
a  diagnosis  of  '  pernicious  ansemia.'  There  is  often  a  trivial 
but   continuous   pyrexia,   and  persisting  albuminuria   is   not 


88  SURGERY  OF  THE  STOMACH 

seldom  observed.  In  some  cases — those,  for  example,  of 
Baldy  and  Cantwell — symptoms  were  almost  or  entirely 
lacking.  A  tumour  may  be,  but  often  is  not,  felt.  Dilatation 
of  the  stomach  and  vomiting  are  infrequent.  When  vomiting 
is  present,  blood,  either  fresh  or  altered,  is  constantly  noticed, 
and  the  blood  may  be  found  on  careful  examination  of  the 
stools.  Kundrat  places  reliance  as  a  diagnostic  sign  upon 
'  enlargement  of  the  tonsils  with  occasional  swelling  and 
ulceration  of  the  follicles  of  the  tongue.'  The  chemical 
findings  are  similar  to  those  in  carcinoma.  The  HCl  is 
absent  from  an  early  stage.  Lactic  acid  and  the  Oppler- 
Boas  bacilli  are  found  (Schlesinger,  Zeit.  f.  Klin.  Med., 
vol.  xxxii.). 

A  study  of  recorded  cases  shows  that  small  round-celled 
sarcoma  is  generally  diagnosed  as  carcinoma  of  the  stomach, 
whereas  spindle-celled  growths  are  only  recognised  at  the 
time  of  operation  as  having  their  origin  in  that  viscus. 


CHAPTER  VII 

GASTRIC  ULCER 

Although  in  its  earlier  phases  gastric  ulcer  comes  under 
the  care  of  the  physician,  many  of  the  complications 
to  which  it  gives  rise  demand  surgical  intervention,  and, 
in  fact,  can  be  treated  satisfactorily  only  by  surgical  means. 
This  being  so,  it  is  necessary  that  we  should  look  at  the 
subject  before  taking  particular  note  of  those  conditions 
which  specially  call  for  surgical  intervention. 

For  the  present  passing  over  malignant,  tubercular,  and 
syphilitic  ulcers,  the  special  form  of  ulceration  which  pro- 
duces the  complications  calling  for  surgical  treatment  is  the 
simple  ulcer  of  Cruveilhier,  and  to  this  may  be  added  the 
simple  erosion  of  the  mucous  membrane  described  by 
Dieulafoy,  which  at  times  leads  to  serious,  or  even  fatal, 
haemorrhage. 

Although  for  clinical  purposes  it  is  necessary  to  distinguish 
two  distinct  forms  of  ulceration  of  the  stomach,  acute  and 
chronic,  which  appear  to  be  separate  and  characteristic, 
there  are  so  many  intermediate  stages  that  it  is  questionable 
whether  or  no  these  classes  are  so  distinct  as  their  extreme 
varieties  would  seem  to  indicate. 

In  the  classification  of  ordinary  ulcer  of  the  stomach, 
the  following  varieties  seem  to  us  to  include  the  various 
forms : 

I.  Erosions. 

Of  these  Dieulafoy  has  described  two  varieties : 
(a)  Simple  Erosions,  consisting  apparently  of  mere  abrasions 
of  the  surface  epithelium,  which,  though  so  small  as  to  be 


90 


SURGERY  OF  THE  STOMACH 


scarcely  perceptible  to  the  naked  eye,  may  give  rise  to  most 

alarming  haemorrhage.     On  the  post-mortem  table  abrasions 

of  this   kind  may  be  easily  overlooked ;    but  as  seen  when 

haemorrhage  is  going  on,  the  mucous 

membrane  seems   to   be  studded   with 

numerous  bleeding-points. 

{h)  Exulceratio  Simplex. — In  the  form 

to  which    Dieulafoy  applied    this   term 

the  lesions  are  rather  more  extensive, 

and  the  surface  layers  are  removed  to 

such    an     extent    that    the     arterioles 

running  under  the  muscularis  rhucosse 

are  exposed.     This  form  of  ulceration 

may  give  rise  to  terrible  haemorrhages 

that    may  prove    rapidly   fatal    unless 

arrested  by  treatment. 

Fig.  23. — Multiple 
Round  Ulcers. 


(No.  2,400,  Royal  College 
of  Surgeons'  Museum.) 


II.  Simple  Ulcer. 

The  second  form,  described  by  Cru- 
veilhier,  includes  : 

{a)  The  Acute  Round  Ulcer,  which  is  most  frequently  found 
in  women,  often  in  chlorotic  young  women,  and  which  is  apt 
to  be  complicated  by  profuse  haemorrhage  and  by  perfora- 
tion. 

{b)  The  Chronic  Form,  irregular  in  outline,  associated  with 
thickening  of  the  edges,  and  frequently  found  in  men — 
according  to  Dr.  Seymour  Taylor,  in  the  proportion  of 
72  per  cent,  in  males  to  28  per  cent,  in  females.  This  form 
is  one  which  gives  rise  to  the  greater  number  of  complica- 
tions with  which  the  surgeon  has  to  deal. 

According  to  our  experience  in  the  operating  theatre,  this 
chronic  form  of  ulcer  occurs  very  frequently  in  women,  and, 
in  fact,  we  have  operated  on  quite  as  many  cases  in  the 
female  as  in  the  male.  Probably  there  is  no  hard-and-fast 
line  of  demarcation  between  acute  and  chronic  ulcers,  just 
as  it  is  difficult  to  define  the  boundary  between  simple 
erosions  and  the  '  exulceratio  simplex '  of  Dieulafoy.  Not- 
withstanding that  there  has  been  much  investigation  into 
the  subject,  and  that  many  experiments  have   been  made. 


GASTRIC  ULCER 


91 


with  the  view  of  elucidating  the  pathology  of  gastric  ulcera- 
tion, the  question  can  scarcely  be  held  as  settled,  nor  can 
any  of  the  theories  at  present  put  forward  be  supposed  to 
account  for  all  cases.  It  is  not  our  intention  to  discuss,  or 
even  to  state,  all  the  theories  supported  by  the  different 
authorities ;  but  we  shall  mention  one  or  two  which  seem 
to  afford  a  likely  explanation  for  a  large  proportion  of  cases. 
It    is    well    known    that    in    many    apparently    functional 


Fig.  24. 


-Acute  Round  Ulcers  in  the  Stomach  of  a  Woman  aged 

Twenty. 


Death  from  perforation  in  forty  hours.  The  perforation  is  very  small,  on  the 
anterior  wall  close  to  the  middle  of  the  lesser  curvature,  and  there  is  another 
ulcer  nearer  the  cardiac  orifice.  (No.  2,395a,  Royal  College  of  Surgeons' 
Museum.) 

disturbances  of  the  stomach  slight  abrasions  of  the  mucous 
membrane  occur,  which  heal  readily  enough  under  ordinary 
circumstances.  Many  experimenters  have  produced  similar 
abrasions  in  animals,  and  have  found  them  to  heal  equally 
rapidly  by  proliferation  from  the  epithelial  margins  of  the 
sores  so  formed.  Quincke  and  Daettwyler  {Correspondenz- 
hlatt  fur  Schweitzer  Aertze,  1875,  p.  loi),  in  addition  to 
injuring  the  mucous  membrane  of  the  stomach,  rendered 


92  SURGERY  OF  THE  STOMACH 

the  animals  experimented  on  anasmic  by  bleeding  them, 
and  then  found  that  the  abrasions  did  not  spontaneously 
heal,  but  continued  to  form  distinct  ulcers,  and  in  some 
cases  even  went  on  to  perforation.  Another  experimenter 
(Silbermann,  Deutsche  Med.  Woch.,  1886,  No.  29)  produced 
haemoglobinuria,  and  found  a  similar,  though  less  marked, 
result  follow  the  production  of  abrasions  of  the  gastric 
mucous  membrane.  It  is  possible  that  these  experiments 
explain  the  frequency  with  which  simple  ulcer  of  the 
stomach  is  found  in  anasmic  young  women,  while  the  latter 
series  may  account  for  those  obscure  cases  of  perforating 
ulcer  of  the  duodenum  following  on  extensive  burns,  since 
it  is  well  known  that  in  a  fair  proportion  of  cases  of  burning 
there  is  extensive  destruction  of  red  blood  corpuscles,  as 
shown  by  the  existence  of  haemoglobinuria.  More  recently, 
the  recognition  of  the  fact  that  in  a  very  large  proportion  of 
all  cases  of  gastric  ulcer  the  gastric  juice  is  hyperacid  has  led 
to  a  belief  that  this  is  the  chief  factor  in  the  production  of 
the  lesion.  It  is  quite  possible  that  the  hyperacidity  may, 
in  the  presence  of  other  conditions,  determine  the  production 
of  ulceration  ;  but  since  in  many  other  morbid  conditions  of 
the  stomach  the  gastric  juice  may  have  an  excess  of  hydro- 
chloric acid,  and  yet  no  ulceration  be  induced,  it  can  only  be 
considered  as  one  of  the  contributing  causes.  Moreover, 
well-marked  cases  of  gastric  ulceration  have  been  put  on 
record  in  which  there  was  not  only  a  deficiency,  but  even  an 
entire  absence,  of  hydrochloric  acid,  and  there  has  been  no 
evidence  brought  forward  to  show  that  the  hyperacidity  is 
not  an  effect  rather  than  the  cause  of  the  ulceration. 

None  of  the  other  theories  advanced  have,  so  far  as  we 
know,  any  strong  basis  or  support  in  clinical  observations, 
but  seem  to  be  founded  on  the  production  of  conditions  in 
the  laboratory  which  occur  very  infrequently,  if  at  all, 
in  man.  Notably  is  this  the  case  with  the  theory  that 
ulcers  mostly  arise  in  connection  with  the  results  of  em- 
bolism of  the  smaller  arteries  in  the  stomach  ;  for  even  if 
solid  particles  be  injected  into  the  general  blood-stream  in 
animals,  the  stomach  is  one  of  the  organs  in  which  they  are 
least  commonly  found. 


GASTRIC  ULCER  93 

The  acute  simple  ulcer  differs  very  materially  in  shape  and 
general  appearance  from  the  chronic  ulcer.  As  a  rule,  in  the 
acute  variety  the  ulcer  is  small,  round,  or  oval,  and  has  the 
appearance  of  being  punched  out ;  its  walls  are  not — at  least, 
post-mortem — infiltrated  to  any  marked  extent,  and  the  base, 
though  smooth,  does  not  usually  show  much  evidence  of 
granulations,  the  submucous,  muscular,  or  serous  coat  being 
laid  bare.  The  general  shape  of  the  ulcer  is  that  of  a 
truncated  cone,  with  its  base  towards  the  interior  of  the 
stomach,  the  layers  from  within  outwards  being  successively 


Fig.  25. — A  Small,  Universally  Ulclkatld  Stomach,  5  inches  long, 
6  INCHES  IN  Widest  Circumference,  with  the  Coats  three  or 
FOUR  Lines  thick. 

From  an  old  gentleman  of  seventy,  accustomed  to  take  up  to  3ii  of  Colchicum 
wine  for  gout.  Although  he  abstained  for  nine  months  before  death  he  had 
incessant  pain  and  vomiting. 

less  destroyed.  This  has  been  supposed  to  give  great  support 
to  the  theory  that  the  acute  ulcer  takes  origin  from  some 
interference  wdth  the  blood-supply ;  but  Dr.  Soltau  Fenwick 
has  shown  that,  even  if  all  the  coats  of  the  stomach  are 
equally  destroyed  by  cautery,  the  ulcer  ultimately  assumes 
the  usual  funnel  shape.  Up  to  the  margin  of  the  ulcer  the 
mucous  membrane  is  normal  in  all  respects  and  quite  supple. 
On  the  other  hand,  the  chronic  ulcer  is  not  infrequently 
large,  and  is  usually  irregular  in  shape  ;  the  margins  are 
hard,  indurated,  and  infiltrated,  and  the  base  shows  evidences 
of  cicatricial  processes.     Much  more  frequently  also  in  this 


94  SURGERY  OF  THE  STOMACH 

variety  the  peritoneal  coat  is  thickened,  and  adhesions  to 
neighbouring  viscera,  especially  the  liver  and  pancreas,  form, 
and  it  is  not  uncommon  for  the  base  to  be  formed  by  the 
tissues  of  one  of  these  organs.  In  chronic  ulcer  the  long 
axis  is,  as  a  rule,  transversely  placed,  but  this  is  by  no  means 
invariable.  The  mucous  membrane  for  some  space  round 
the  ulcerated  area  is  thickened  and  infiltrated,  and  according 
to  Dr.  Fenwick  ('  Ulcer  of  the  Stomach  and  Duodenum,' 
London,  igoo)  there  is  not  infrequently  varicosity  of  the 
small  venules  in  the  immediate  neighbourhood. 


■4 


Fig.  26. — Chronic  Ulcer  of  Stomach  showing  Characteristic  Pucker- 
ing AND  Contraction  the  Result  of  Healing. 

(No.  2,402a,  Royal  College  of  Surgeons'  Museum.) 

Acute  ulcer  is  much  more  frequently  multiple  than  is  the 
chronic  ulcer — probably  half  the  cases  of  acute  ulceration 
present  more  than  one — while  in  the  case  of  chronic  ulcera- 
tion it  is  comparatively  rare  to  find  multiple  ulcers,  though 
at  times  the  shape  of  that  found  is  suggestive  of  the  coales- 
cence of  several  ulcerated  areas. 

The  different  regions  of  the  stomach  are  very  variously 
affected  in  this  disease.  According  to  Brinton,  in  43  cases 
out  of  100  the  ulcer  is  situated  on  the  posterior  surface,  in 
27  at  the  lesser  curvature,  in  16  at  the  pylorus,  in  6  on  both 
anterior  and  posterior  surfaces,  in  4  on  the  anterior  surface 
alone,  in  2  at  the  cardiac  end,  and  in  2  on  the  greater 
curvature. 

Welch  gives  793  cases  distributed  as  follows  :  235  on  the 


GASTRIC  ULCER 


95 


posterior  surface,  288  on  the  lesser  curvature,  95  at  the 
pylorus,  96  on  the  anterior  wall,  50  at  the  cardia,  29  at  the 
fundus,  and  27  on  the  greater  curvature. 

Dr.  Fenwick    has    collected    1,015    cases,    and   gives   the 


Fig.  27. — Ulcer  midway  between  Cardiac  and  Pyloric  Orifices,  near 
Lesser  Curvature,  eroding  Splenic  Artery,  on  which  is  a  small 
Aneurysmal  Dilatation. 


From  a  man  of  fifty- six. 


Death  from  haemorrhage.     (No.  2,401a,  Royal  College 
of  Surgeons'  Museum.) 


following  table  showing  the  relative  frequency  of  the  disease 
in  different  reg-ions  of  the  stomach  : 


Cases. 

Per  cent 

Pylorus 

...      158 

15-6 

Lesser  curvature  . . . 

...      366 

36 

Posterior  surface  ... 

...      254 

25 

Cardia 

...        80 

7-9 

Great  curvature    ... 

...        42 

4-14 

Anterior  surface    ... 

...        82 

8 

Fundus 

■■•       33 

3-3 

It  is  noteworthy,  however,  that,  of  his  own  cases,  the 
chronic  and  acute  ulcers  (which  are  not  distinguished  in 
the  above  table)  markedly  differ  in  their  distribution.     Of 


96 


SURGERY  OF  THE  STOMACH 


109  cases,  70  chronic  ulcers  were  distributed  thus  :  53  in  the 
pyloric  region,  7  in  the  middle  zone  of  the  stomach,  and 
10  towards  the  cardiac  end  ;  the  remaining  39,  the  acute 
ulcers,  had  the  following  distribution  :  13  in  the  pyloric, 
14  in  the  middle,  and  12  in  the  cardiac  region.  Thus, 
75  per  cent,  of  the  chronic  ulcers  were  in  the  pyloric  region, 

while  in  acute  ulceration  all 
three  divisions  were  fairly 
equally  affected. 

This  distribution  of  ulcers 
generally,  and  especially  of  the 
chronic  variety,  has,  as  will  be 
seen  later,  a  most  important 
bearing  on  the  question  of 
surgical  intervention  in  cases 
with  a  long-continued  history 
of  gastric  trouble. 

The  questions  of  the  age  and 
sex  of  the  patient  are  of  great 
importance  in  helping  to  a  de- 
cision as  to  the  character,  and 
therefore  the  site,  of  the  lesion, 
and  require  attention  here. 
Fig.  28.— Pyloric  Ulcer  show-  Judging  from  clinical  experi- 
iNG   Small  Perforation,  and  rather    than     from     nn^t 

ANOTHER  CAUSING  CONTRACTION   ^"^^    Tdiner    luau     irom     posi- 


OF  Pylorus. 


mortem      records,      it      would 
(No.  2,398,  Royal  College  of  Sur-  appear   that    ulceration    of   the 

geons  Museum.)  ^^ 

stomach  occurs  about  three 
times  as  frequently  in  women 
as  in  men.  On  the  other  hand,  pathological  reports  would 
lead  one  to  suppose  that  gastric  ulcers  were  much  less  dis- 
proportionately distributed  between  the  sexes ;  thus,  Welch 
gives  the  relative  proportions  as  40  per  cent,  in  men  and 
60  per  cent,  in  women,  while  out  of  2,031  cases  of  open  ulcer 
collected  by  Fenwick,  1,227  occurred  in  women  and  804  in 
men.  This  apparent  discrepancy  is  probably  to  be  accounted 
for  by  the  fact  that  women  are  more  liable  to  suffer  from 
the  acute  affection,  while  the  chronic  process  occurs  more 
frequently  in  men,  and  is  more  often  fatal. 


GASTRIC  ULCER 


97 


That  this  is  the  true  explanation  cannot  at  present  be 
definitely  stated,  since  in  most  collected  cases  no  distinction 
is  made  between  acute  and  chronic  ulcers ;  but  an  examina- 
tion of  8g  cases  made  by  Fenwick  points  so  strongly  in  this 
direction  that  there  can  be  little  doubt  but  that  this  view 
will  ultimately  be  established.  Of  his  8g  cases,  30  were 
acute,  and  only  10  per  cent,  occurrei  in  men,  while  59  were 
chronic  ulcers,  and  of  these  almost  73  per  cent,  were  in  men. 


Fig.    29. — A   Perforating   Round    Ulcer    causing    Death    in    a    Lady 

Twenty-two  Years  of  Age. 

(No.  2,396,  Royal  College  of  Surgeons'  Museum.) 

Dr.  Seymour  Taylor  gives  almost  identical  figures  in  chronic 
ulcer,  viz.,  72  per  cent,  in  men  and  28  per  cent,  in  women. 

With  regard  to  age  incidence,  all  authorities  are  agreed 
that  gastric  ulcer  is  much  more  frequently  found  in  the 
third  decade  ;  but  here  also  it  should  be  noted  that  accord- 
ing to  the  sex  the  age  incidence  varies,  for  while  75  per  cent, 
of  cases  of  gastric  ulcer  in  women  are  found  before  the  age 
of  thirty,  in  men  only  about  25  per  cent,  occur  before  that 

7 


98  SURGERY  OR  THE  STOJEiCH 

age.  It  is  notable  also  that,  in  the  statistics  referred  to 
above,  in  which  a  distinction  is  made  bet\\"een  acute  and 
chronic  ulcers,  it  was  found  that  of  the  acute  ulcers  over 
70  per  cent,  occurred  within  the  first  thirty  years  of  life, 
while  in  chronic  ulceration  less  than  7  per  cent,  occurred 
within  that  period. 

Though  it  may  be  granted  that  the  numbers  with  which 
this  analysis  deals  are  too  few  to  enable  one  to  dogmatize, 
yet  the  variations  are  too  great  to  be  accounted  for  on  the 
supposition  of  mere  coincidence. 

It  seems,  therefore,  fair  to  conclude  that  chronic  ulcera- 


FiG.  30. — 'Simple    Chroml    Uller  '    oi     Ckuveilhier,    or    the    'Per- 
forating Ulcer  '  of  Rokitansky. 

From  a  girl  of  seventeen.  The  ulcer  is  situated  on  the  anterior  wall  of  the 
stomach  2  inches  from  the  cardiac  orifice.  (No.  2,395,  Royal  College  of 
Surgeons'  Museum.) 

tion  is  much  more  frequently  present  in  men,  and  is  pro- 
portionately much  more  fatal  in  its  effects  than  is  acute 
ulceration  of  the  stomach  :  and  that  the  former  is  a  disease 
of  middle  or  advanced  age,  as  contrasted  with  the  latter, 
which,  as  a  rule,  occurs  within  the  first  three  decades.  Along 
with  this,  however,  must  go  the  qualification  that  chronic 
ulcer  is  often  a  very  slowl}-  progressive  affection,  and  that  it 
may  last  for  over  thirty  years. 

Although  the  following  complications  are  common  to  both 
forms  of  ulcer,  certain  of  them  are  of  greater  frequency  in 


GASTRIC  ULCER 


99 


the  one  than  in  the  other.  For  instance,  the  acute  round 
ulcer  is  more  frequently  followed  by  violent  hgemorrhage  and 
by  perforation  than  the  chronic  ulcer,  yet  the  latter  is  also 
liable  to  be  followed  by  both.  On  the  other  hand,  the 
chronic  ulcer  is  more  frequently  followed  by  cicatricial  con- 
traction of  the  pjdorus,  with  subsequent  dilatation  of  the 
stomach,  and  by  perigastritis  leading  to  disabling  adhesions  ; 
also  by  hour-glass  contraction,  fistula,  and  tumour  of  the 
pylorus  or  of  the  stomach, 
serious  atonic  motor  deficiency, 
severe  gastralgia  with  uncon- 
trollable vomiting,  cancer  of 
the  pylorus,  tetany,  acute  and 
chronic  pancreatitis,  abscess  of 
the  liver,  chronic  hepatitis,  pro- 
found anaemia  (resembling  the 
pernicious  form),  stricture  of 
the  bile-ducts,  jaundice,  catarrh 
of  the  gall-bladder,  and  other 
complications  depending  on  in- 
vasion of  the  neighbouring 
organs.  Both  forms  are  accom- 
panied by  pain,  by  great  loss  of 
flesh  and  strength,  and  at  times 
by  subphrenic  abscess. 

Thus,  it  will  be  at  once  per- 
ceived that  surgery  is  intimately 
concerned    with,    and,   in    fact, 

affords  the  only  effectual  treatment  in,  many  of  these  com- 
plications. 

Prognosis. 

According  to  Lebert,  as  quoted  by  Dr.  Dreschfield,  death 
occurs  in  lo  per  cent,  of  all  ulcers,  6i  per  cent,  occurring 
from  perforation,  and  30-  per  cent,  from  haemorrhage. 
Habershon  says  that  perforation  occurs  in  18  per  cent. 
of  all  cases  of  ulcer  of  the  stomach,  and  Brinton  in 
15  per  cent.,  to  which  must  be  added  the  mortality  from 
hae'morrhage,  which,    according  to    Miiller,    is    11    per   cent. 

7—2 


Fig.  31. — Chronic  Ulcer  cf 
Posterior  Wall  of  Stomach 
ERODING  Pancreas. 

(No.    2,399,    Royal    College   of 
Surgeons'  Museum. 


loo  SURGERY  OF  THE  STOMACH 

of  all  cases  of  ulcer,  the  average  of  all  authorities  being  5  per 
cent. ;  so  that,  allowing  15  per  cent,  to  represent  the  mortality 
from  perforation  and  5  per  cent,  that  from  haemorrhage,  the 
mortality  of  gastric  ulcer  treated  medically  is  at  least  20  per 
cent.  But  Tricomi  {Riforina  Mcdica,  February,  1899)  gives 
even  a  larger  mortality  as  an  argument  in  support  of  his 
views  to  treat  all  obstinate  cases  of  gastric  ulcer  surgically  ; 
and  Brinton  gives  the  mortality  from  all  causes  in  gastric 
ulcer  at  50  per  cent. 

It  is  probable,  however,  that  none  of  the  series  of  statistics 
which  have  been  made  adequately  or  accurately  gives  the 
mortality,  since  practically  in  none  is  any  account  taken  of 
the  large  number  of  deaths  due  to  the  effects  of  those  com- 
plications which  run  a  chronic  course.  This  is  the  more 
likely  to  occur,  since  naturally  the  larger  statistics  are  com- 
piled from  the  records  of  general  hospitals  ;  and  it  is  unlikely 
that  anything  like  a  large  proportion  of  cases,  such  as  we 
refer  to,  should  die  in  hospital.  It  is  probable,  therefore, 
that  20  per  cent,  is  under,  rather  than  above,  the  true 
mortality ;  and  it  is  just  possible  that  the  following  table 
(quoted  from  Einhorn,  '  Diseases  of  the  Stomach  '),  cited 
from  Debove  and  Remond,  adequately  represents  the  truth  : 


100  cases : 

Perfect  cure  ...  ...  ...  ...  ...     50 

Perforation  and  peritonitis  ... 

Foudroyant  haematemesis  . . , 

Pulmonary  tuberculosis 

Inanition 

Different  complications 


13 

5 

20 

5 

7 


Symptoms. 


As  a  rule,  in  acute  ulcer  the  symptomatology  will  be  found 
fairly  characteristic,  though  occasionally  no  evidence  of  the 
presence  of  the  lesion  will  be  afforded  until  alarming  haemor- 
rhage or  perforation,  with  peritonitis,  has  taken  place. 

Generally  there  will  be  a  very  marked  history  of  distinct 
gastric  trouble  supervening  on  anaemia  in  a  young  person. 
The  symptoms  which  are  most  prominent  are  pain,  vomiting 
and  haematemesis.  The  pain  is  located  in  the  epigastrium, 
usually  over  a  small  area,  but  at  times  tending  to  radiate  in 


GASTRIC  ULCER  loi 

different  directions,  mostly  toward  the  left  or  through  to  the 
left  subscapular  region.  It  is  not  in  the  early  stages  con- 
tinuous, though  it  may  become  so  later;  it  is  originated  by 
the  ingestion  of  food,  usually  commencing  shortly  after  a 
meal,  and  persisting  until  the  stomach  has  been  emptied. 

Vomiting  is  frequent  in  simple  acute  ulcer,  and  often  takes 
place  within  an  hour  of  taking  solid  food;  which,  as  a  rule, 
is  immediately  rejected.  Haematemesis  is  also  a  common 
symptom,  and  is  much  more  frequently  copious  in  acute 
ulceration  than  in  the  chronic  form. 


Fig,  32.— Large  Chronic   Ulcer,  3^   by    \\   inches,  on  the   Posterior 
Wall,  adhkrent  to  Pancreas  and  Liver. 

(No.  2,402,  Royal  College  of  Surgeons'  Museum.) 

Chronic  ulcer  is  a  disease  of  middle  or  advanced  age 
rather  than  of  youth,  though  I  have  operated  for  perforation 
from  chronic  ulcer  in  patients  as  young  as  twenty-one  years. 
It  is  frequently  followed  by  pyloric  contraction.  If  bleeding 
occurs,  it  is  usually  less  in  quantity  than  in  the  cases  of  the 
acute  ulcer,  but  the  bleeding  may  be  severe,  and  even  fatal. 

The  characteristic  symptoms  of  gastric  ulcer,  pain  and 
vomiting,  may  be  absent  until  some  complication  supervenes, 
though  usually  they  are  sufficiently  distinct.  The  pain 
frequently  begins  from  one  to  two  or  more  hours  after  food. 
There  is  usually  tenderness  over  the  pylorus,  or  between  the 
xiphoid  and  right  costal  margin.     Vomiting  is  very  irregular, 


I02  SURGERY  OF  THE  STOMACH 

but  when  present  is  characteristic.  The  vomit  is  often  large 
in  quantit}',  containing  much  mucus,  and  it  sometimes  con- 
sists largely  of  grumous  or  coffee-ground-like  material ;  it  is 
often  foetid,  and  if  there  be  dilatation  there  will  be  signs  of 
fermentation,  with  sarcina  on  microscopic  examination. 
The  symptoms  vary  very  much,  and  may  disappear  for  ^^■eeks 
together.  \\!e  have  observed  and  operated  on  cases  where  the 
symptoms  have  been  going  on  for  five,  seven,  fifteen,  seven- 
teen and  twenty-five  years,  with  more  or  less  long  intervals, 
when  the  symptoms  were  in  abeyance.  Dilatation  of  the 
stomach  is  a  frequent  complication,  and  is  dependent  on 
pyloric  contraction,  the  result  of  cicatrization.  Loss  of 
flesh  is  always  present ;  it  may  be  well  marked,  especially  in 
the  later  stages,  and  in  some  cases  is  extreme,  extending  to 
half  the  body-weight.  A  tumour  of  the  pylorus  is  not  in- 
frequently present,  and  may  resemble  one  due  to  malignant 
disease. 

Diagnosis. 

The  well-known  symptoms  of  pain  after  food  and  epi- 
gastric tenderness,  with  vomiting  and  bleeding,  as  shown 
by  hcematemesis  and  melsna,  are  usually  sufficiently  char- 
acteristic of  gastric  ulcer ;  but  in  some  cases  hasmatemesis 
and  vomiting  may  be  absent,  and  only  painful  indigestion 
and  tenderness  may  be  noticed ;  or  even,  in  others,  all  the 
symptoms  may  be  latent.  The  surgeon  cannot  afford  to  pass 
over  the  diagnosis,  but  must  confirm  it  personally  before 
deciding  on  the  question  of  surgical  treatment. 

Doubtless  before  he  sees  the  case  it  will  have  been  settled 
by  the  physician  that  the  patient  is  not  suffering  from  simple 
gastralgia  due  to  ansemia  and  hypersesthesia  of  the  stomach, 
owing  to  the  absence  of  localized  tenderness  and  of  hyper- 
acidity of  the  gastric  juice,  as  well  as  from  the  irregularity 
of  the  vomiting  and  pain,  which  may  occur  quite  independent 
of  the  ingestion  of  food.  He  may,  however,  be  called  on  to 
negative  cancer  of  the  stomach  by  noting  the  length  of  time 
over  which  the  symptoms  may  have  extended,  the  absence 
of  a  tumour,  the  presence  or  increase  in  quantity  of  free 
hydrochloric  acid  in  the  vomit,  the  absence  of  coffee-ground 


GASTRIC  ULCER  103 

vomiting  and  of  cachexia,  and  the  onset  of  the  disease  in 
youth  or  before  middle  hfe,  though  it  must  be  borne  in  mind 
that  cancer  may  occur  even  in  adolescence ;  and  one  of  us — 
A.  W.  M.  R. — has  performed  gastro-enterostomy  for  cancer  of 
the  pylorus  in  a  young  woman  of  twenty-one,  the  accuracy 
of  the  diagnosis  being  confirmed  some  months  later  by  an 
autopsy.  The  diagnosis  between  gallstones  and  ulcer  will 
usually  be  indicated  b}^  the  irregularity  of  the  paroxysms  of 
pain,  which  in  gallstone  colic  occur  quite  independent  of 
food,  by  the  character  and  site  of  the  pain,  the  presence  of 
jaundice  and  the  character  of  the  vomiting,  which  in  chole- 
lithiasis usually  comes  on  soon  after  the  pain  begins,  and 
persists  long  after  all  food  has  been  rejected. 

In  the  differential  diagnosis  between  ulcer  of  the  duodenum 
and  ulcer  of  the  stomach,  the  occurrence  of  the  former  more 
frequently  in  men  than  in  women,  and  after  middle  age, 
the  presence  of  melsena  often  without  haematemesis,  the  pain 
occurring  from  an  hour  to  two  hours  after  food,  and  the 
tenderness  situated  to  the  right  of  the  middle  line,  will 
usually  afford  sufficiently  characteristic  indications. 

We  would  here  point  out,  as  bearing  on  the  site  of  the 
ulcer,  the  importance  of  the  character  and  site  of  the  pain, 
which  in  gastric  ulcer  is  usually  definitely  localized  and  asso- 
ciated with  tenderness  on  pressure.  The  tender  area  is  in 
the  upper  abdominal  region,  the  position  being  more  or  less 
to  the  right  or  left  of  the  middle  line,  according  to  the  site  of 
the  ulcer.  For  instance,  an  ulcer  on  the  anterior  surface  of 
the  stomach  near  the  cardiac  end  is  usually  associated  with 
tenderness  between  the  left  costal  arch  and  the  mid-line,  and 
relieved  by  the  dorsal  decubitus ;  but  if  the  pylorus  be 
involved,  the  tender  spot  will  lie  between  the  right  costal 
margin  and  the  middle  line,  and  the  pain  is  relieved  by  lying 
on  the  left  side,  and  aggravated  by  turning  to  the  right.  An 
ulcer  on  the  posterior  wall  of  the  stomach  gives  rise  to  less 
epigastric  tenderness,  and  the  pain  is  felt  more  in  the  back 
beneath  the  left  scapula,  or  close  to  the  spinal  column, 
opposite  the  attachment  of  the  ninth,  tenth,  and  eleventh 
ribs.  If  adhesions  have  formed  between  the  pylorus  and 
the  liver  or  gall-bladder,  the  pain  may  radiate  toward   the 


104  SURGERY  OF  THE  STOMACH 

right  infrascapular  region.  When  the  ulcer  is  on  the 
posterior  wall,  dorsal  decubitus  increases  the  pain,  which 
may  be  relieved  by  lying  on  the  face,  leaning  forward,  or 
even  by  assuming  the  erect  posture.  In  all  cases  of  ulcer 
the  pain  is  usually  increased  after  food,  but  the  time  of  the 
onset  of  pain  after  eating  is  significant.  Thus,  an  ulcer 
close  to  the  cardiac  orifice  of  the  stomach  causes  pain 
immediately  after  food  has  been  swallowed,  or  the  pain 
may  even  start  as  the  food  is  being  swallowed.  On  the 
other  hand,  in  ulcer  of  the  pylorus  the  pain  frequently  does 
not  begin  until  from  one  to  two  hours  after  meals.  If  the 
pain  is  severe,  vomiting  usually  occurs,  sometimes  imme- 
diately after  food,  at  others  not  for  an  hour  or  two,  and  the 
act  of  vomiting  usually  gives  immediate  relief.  With  regard 
to  hsematemesis,  which  is  said  to  occur  in  about  80  per  cent, 
of  cases  of  gastric  ulcer,  and  melaena,  which  is  usually  asso- 
ciated with  ulcer,  but  sometimes  occurs  without  hsematemesis, 
they  will  be  considered  later ;  for  haemorrhage  is  one  of  the 
important  complications  on  which  the  opinion  of  the  pro- 
fession, so  far  as  treatment  is  concerned,  is  not  yet  by  any 
means  crystallized. 

Latent  ulcers  are  not  uncommon ;  Savariaud  gives  their 
proportion  as  20  per  cent,  of  all  cases  of  gastric  ulcer.  It  is 
said  that  such  ulcers  are  always  of  the  acute  round  variety, 
but  our  experience  in  three  cases,  where  we  had  to  operate 
for  perforation  without  any  previous  symptoms  pointing  to 
ulceration,  would  lead  us  to  form  a  different  opinion  ;  for  in 
both  considerable  thickening  was  found  around  the  ulcers, 
showing  that  the  disease  must  have  existed  in  a  latent  form 
for  some  considerable  time.  It  is  difficult  to  explain  why 
some  of  these  ulcers  should  exist  without  producing  symp- 
toms until  either  perforation  or  violent  haemorrhage  takes 
place.  In  the  cases  we  have  seen  the  ulcer  has  been  near 
the  lesser  curvature  of  the  stomach,  and  this  might  possibly 
afford  an  explanation,  since  in  this  situation  they  would  be 
brought  less  intimately  into  contact  with  food. 


CHAPTER  VIII 

GASTRIC  ULCER  AND  ITS  COMPLICATIONS 

The  complications  of  gastric  ulcer  are  no  less  numerous 
than  serious,  and  before  describing  each  separately,  and 
giving  the  appropriate  treatment,  it  will  be  well  to  mention 
them  collectively.     They  are  as  follows  : 

1.  Local  peritonitis,  or  perigastritis,  ending  in  adhesions. 

2.  Local  peritonitis,  ending  in  suppuration  and  a  localized 
abscess. 

3.  Subphrenic  abscess. 

4.  Abscess  of  liver,  pancreas,  or  spleen. 

5.  Fistula  between  the  stomach  or  pylorus  and  adjoining 
organs,  or  even  with  the  surface  of  the  body. 

6.  Acute  perforation  of  the  stomach  wall. 

7.  General  peritonitis. 

8.  Haematemesis  and  melasna. 

9.  Dilatation  of  the  stomach. 

10.  Tumour  of  stomach  or  pylorus. 

11.  Cicatricial  stenosis  of  pylorus. 

12.  Hour-glass  stomach. 

13.  Spasm  of  pylorus  producing  intermittent   narrowing 
(Reichmann's  disease). 

14.  Atonic  motor  deficiency. 

15.  Severe  gastralgia. 

16.  Persistent  vomiting. 

17.  Tetany. 

18.  Acute  or  chronic  pancreatitis. 

19.  Profound  anaemia  resembling  the  pernicious  form, 

20.  Pressure    on,    or    stricture    of,    the    bile-ducts    with 
jaundice. 


io6  SURGERY  OF  THE  STOMACH 

2  1,  Catarrh  of  gall-bladder  from  adhesions  producing 
attacks  like  those  of  cholelithiasis. 

22.  Great  loss  of  flesh  and  strength,  ending  in  phthisis. 

23.  Cancer  secondary  to  ulcer — '  ulcus  carcinomatosum.' 
The  treatment  of  gastric  ulcer  is  at  first  essentially  medical, 

and  when  properly  carried  out,  and  for  a  sufficient  length  of 
time,  it  is  usually  completely  successful.  Leube  says  that 
one-half  or  three-fourths  of  all  cases  will  be  cured  by  four  or 
five  weeks  of  treatment,  but  that  if  not  cured  in  that  time 
they  will  not  be  cured  by  medical  treatment  alone.  Unfor- 
tunately, however,  in  many  cases  treatment  is  stopped  as 
soon  as  relief  to  pain  is  obtained,  and  long  before  the  ulcer  is 
healed.  In  some  cases  this  may  be  due  to  the  uncertainty 
of  diagnosis,  or  from  the  impatience  of  the  patient ;  perhaps 
in  others  to  ignorance  as  to  how  long  it  takes  to  secure  the 
healing  of  the  gastric  ulcer.  The  earlier  in  the  course  of  the 
disease  that  radical  treatment  in  the  shape  of  dieting  and 
rest  is  adopted,  the  less  prolonged  will  the  treatment  need  to 
be,  and  the  more  likely  is  it  to  be  effectual ;  but  probably  the 
very  earliest  timie  a  patient  should  be  allowed  to  be  out  of  bed 
is  from  a  fortnight  to  a  month  after  all  pain  and  tenderness 
have  disappeared.  Failing  this  thorough  treatment,  relapses 
will  be  certain  to  occur,  and  in  the  long-run  complications 
will  supervene  or  the  ulcer  will  become  chronic,  when,  though 
medical  treatment  may  relieve  in  some  cases,  cure  can  only 
be  looked  for  in  the  greater  number  by  surgical  methods. 

In  considering  the  treatment  of  ulcer  of  the  stomach,  it  is 
useful  to  hold  in  view  the  course  of  an  ulcer  of  the  leg,  which 
directly  the  healing  stage  has  arrived  becomes  free  from  pain. 
But  this  neither  indicates  that  healing  is  completed  nor  that 
care  may  cease,  and  should  treatment  be  abandoned  and  the 
ulcer  become  chronic,  though  it  may  even  be  painless,  it  is 
at  any  time  liable  to  become  inflamed  or  to  extend ;  more- 
over, the  surrounding  tissues  become  infiltrated  with  lymph, 
and  contraction  occurs,  which  in  a  hollow  viscus  would  soon 
end  in  stricture,  as  in  the  leg  it  tends  to  drag  on  the  sur- 
rounding skin  and  produce  constriction  of  the  limb. 

The  medical  treatment  of  ulcer  of  the  stomach  consists 
chiefly  in  S3^stematic  dieting  and  rest. 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  107 

The  following  method  of  treatment,  which  is  employed  by 
Dr.  Robert  Saundby  {British  Medical  Journal,  January  20, 
1900,  p.  122),  is  one  that  should  be  efficient  in  ordinary 
cases ;  but  in  severe  cases  it  may  be  necessary  to  keep  the 
stomach  void  of  food  for  several  days  and  to  feed  by  enemata  ; 
and  then  absolute  rest  in  bed  may  be  required  over  a  greater 
length  of  time,  and  abstention  from  solids  will  have  to  be 
further  delayed. 

'  It  is  a  rule  to  which  attention  may  well  be  called,  that, 
in  the  management  of  stomach  disorders,  obstinate  vomiting 
should  be  treated  by  absolute  rest  in  bed,  and  the  adminis- 
tration of  the  simplest  food  in  small  quantities  at  regular 
intervals.  I  generally  prescribe  an  ounce  of  milk  and  lime- 
water  every  hour,  with  the  following  mixture  : 

Sulphate  of  magnesium  ...  ...  40  grains 

Sulphate  of  iron       ...  ...  ...        2       ,, 

Diluted  sulphuric  acid  ...  ...  15  minims 

Peppermint-water  ...  to         i  ounce 

three  times  a  day.  The  milk  and  lime-water,  if  borne  with- 
or.t  pam  and  vomiting,  as  is  almost  invariably  the  case,  is 
increased  every  da}-  or  every  second  day  up  to  4  ounces 
every  hour,  and  afterwards  the  diet  is  gradually  increased  by 
the  addition  of  bread-and-milk,  minced  chicken,  and  minced 
mutton  at  intervals,  so  that,  about  twenty-one  days  after 
admission,  the  patient  is  usually  able  to  eat  the  ordinary 
house-diet  of  the  hospital.  xA.fter  this  has  been  taken  for 
two  or  three  days  the  patient  is  allowed  to  get  up,  and  at 
the  end  of  a  month  is  sent  to  a  convalescent  home.  When 
the  anaemia  is  marked  the  mixture  may  be  supplemented  by 
pil.  ferri,  5  grains  or  more,  three  times  a  day.  Should  the 
patient  not  be  able  to  tolerate  so  much  milk  and  lime-water 
in  the  first  instance,  h  ounce  may  be  given,  or,  if  there  be 
only  pain  without  vomiting,  a  mixture  of  bismuth  and  soda 
may  be  substituted  for  that  of  iron  and  magnesia. 

In  those  cases  which  have  recently  suffered  from  haema- 
temesis,  it  is  desirable  to  give  nothing  by  the  mouth  until 
forty-eight  hours  have  elapsed  after  the  vomiting  of  blood 
has  stopped,  and  during  that  time  I  feed  them  by  the  follow- 
ing nutrient  enema,  given  every  four  hours  :   One  egg  beaten 


Io8  SURGERY  OF  THE  STOMACH 

up  with  one  teaspoonful  of  brand}',  and  made  up  to  4  ounces 
with  milk.  Should  there  be  any  irritability  of  the  rectum, 
20  to  30  drops  of  laudanum  may  be  added.  While  the  hgema- 
temesis  persists,  I  place  an  ice-bag  upon  the  epigastrium, 
although  I  am  by  no  means  certain  that  it  does  any  good, 
and  I  allow  the  patient  to  suck  small  pieces  of  ice  if  she 
wishes.  If  necessar)',  to  relieve  pain  or  to  keep  the  patient 
quiet,  I  order  a  hypodermic  injection  of  ]^  to  ^  grain  of 
morphine.  It  is  of  great  importance  to  see  that  the  patient 
is  able  to  eat  ordinary  food  with  comfort  before  she  leaves 
the  hospital,  and  I  always  try  to  impress  upon  each  one  the 
importance  of  continuing  to  do  this  after  she  returns  home. 
Many  of  these  patients  have  been  dieting  themselves  for  so 
long  a  time,  and  have  become  convinced  partly  as  the  result 
of  injudicious  advice,  partly  from  their  own  experience,  that 
they  cannot  eat  the  same  food  as  other  people,  that  they 
have  suffered  in  health  from  an  insufficient  nutrition,  and 
have  entered  a  vicious  circle  in  which  the  anaemia  is  kept  up 
by  want  of  food,  so  that  the  predisposing  cause  persists,  and 
recovery  is  impossible  until  the  circle  is  broken  ;.  it  is  there- 
fore of  the  utmost  importance  to  prove  to  your  patient  that 
she  can  take  ordinary  food.  It  is  also  very  desirable  that 
she  should  continue  to  take  iron  for  some  time  after  leaving 
the  hospital,  and  I  may  perhaps  be  allowed  to  mention  that 
the  dose  of  sulphate  of  magnesium  in  the  mixture  should  be 
adjusted  to  the  needs  of  each  case,  and  may  be  very  properly 
increased  or  diminished  at  different  times  as  required.' 

The  surgical  treatment  of  intractable  or  relapsing  gastric 
ulcer  is,  in  the  greater  number  of  cases,  the  only  satisfactory 
method  of  dealing  with  these  refractory  cases,  and  operation 
should  be  resorted  to  at  a  much  earlier  period  than  has 
hitherto  been  the  custom,  and  always  before  the  patient  is 
so  far  reduced  by  pain  and  starvation  or  the  supervention 
of  serious  complications  that  weakness  and  ansemia  render 
any  operative  procedure  hazardous. 

Ulcer  of  the  stomach  is  a  much  more  serious  matter  than 
is  generally  recognised,  for,  according  to  various  authors,  it 
has  a  mortality,  when  treated  by  general  and  medical  means 
only,  of  from  20  to  50  per  cent.,  and  the  excuses  of  a  few 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  109 

years  ago,  that  there  is  a  great  responsibihty  in  recommend- 
ing surgical  treatment,  either  from  the  uncertainties  of 
diagnosis  or  from  the  risk  of  operation,  can  no  longer  avail, 
since  the  diagnosis  of  gastric  ulcer,  thanks  to  the  researches 
of  Ewald,  Hemmeter,  Einhorn,  and  others,  has  been  brought 
to  a  greater  state  of  perfection  than  exists  in  many  other 
obscure  diseases  where  radical  treatment  has  to  be  adopted 
on  much  more  slender  foundations ;  and,  fortunately,  now 
that  the  mortality  in  operations  for  simple  diseases  of  the 
stomach  has  been  reduced  in  the  hands  of  experienced 
surgeons  to  5,  or  almost  5,  per  cent.,  the  risk  of  surgical 
treatment  cannot  be  advanced  even  by  the  most  ardent 
opponents. 

In  England  w^e  are  not  prepared  to  subscribe  fully  to  the 
views  of  Tricomi  {Riforina  Medica,  i8gg),  who  draws  a 
parallel  between  the  treatment  of  hernia  and  that  of  ordinary 
gastric  ulcer,  and  proposes  that  as  hernia  is  treated  radically 
with  success,  so  gastric  ulcer  should  be  treated  radically  by 
the  performance  of  gastro-enterostomy. 

Heydenreich  {Sem.  Med.,  February  2,  i8g8)  argues:  'The 
death-rate  from  all  cases  of  gastric  ulcer  is  from  25  to 
30  per  cent.,  but  from  gastro-enterostomy  only  16*2  per 
cent. ;  therefore  the  operation  has  less  danger  than  the 
disease.  Another  advantage  of  not  waiting  for  complications 
is  that  the  patient  is  in  better  health.  At  any  rate,  cases 
which  do  not  improve  with  medical  treatment  in  a  reason- 
able time  should  be  treated  surgically.  The  question  of 
medical  versus  surgical  treatment  in  this  class  of  cases  is 
one  that  can  be  much  simplified  by  a  careful  study  of 
statistics.' 

At  the  time  Mayo  Robson  delivered  the  Hunterian 
Lectures  in  March,  igoo,  he  had  been  able  to  collect 
184  operations  for  gastric  ulcer  (excluding  those  for  perfora- 
tion and  hsemorrhage),  of  which  157  recovered  and  31  died, 
thus  giving  a  mortality  of  i6"4  per  cent.  These  included 
34  personal  cases,  which  will  be  referred  to  later. 

Now,  although  the  deaths  from  gastric  ulcer,  medically 
treated,  averaged  25  per  cent.,  and  those  from  even  the 
worst    and    most    inveterate    cases    of    ulcer,    when    treated 


no  SURGERY  OF  THE  STOMACH 

surgically,  only  i6  per  cent,  at  the  time  of  those  lectures, 
yet  the  difference  did  not  then  appear  so  great  as  to  make  it  - 
desirable    or    prudent   very    strongly    to    advocate    surgical 
treatment    until    the    disease   had   become    chronic   or   until 
serious  complications  had  ensued. 

To-day,  however,  the  facts  are  ver}^  materially  altered  by 
the  all-round  improvement  in  operations  on  the  stomach, 
and  the  contrast  of  25  per  cent,  of  deaths  in  cases  treated 
medically  and  5  per  cent,  as  shown  in  our  latest  statistics  in 
those  treated  surgically  in  the  worst  and  most  complicated 
cases  is  so  striking  that  we  feel  it  incumbent  to  urge  most 
strongly  that,  although  cases  of  gastric  ulcer  should  first  be 
submitted  to  medical  treatment,  yet  if  such  treatment  fails 
to  cure  in  a  reasonable  time,  or  if  relapses  occur  on  the 
resumption  of  solid  food,  then  medical  should  give  place  to 
surgical  treatment:  for  it  is  unfair  to  the  surgeon  to  hand 
over  to  him  almost  moribund  cases,  and  it  is  unjust  to  the 
patients  to  persist  in  dosing  them  wdth  medicine  or  otherwise 
treating  palliatively  cases  that  can  only  be  benefited  or  cured 
by  surgical  means. 

Operative  Treatment. — Before  the  abdomen  is  opened  it  is 
quite  impossible  to  say  what  operation  or  operations  will  be 
required,  and  the  surgeon  must  be  prepared  to  adapt  him- 
self to  circumstances  on  discovering  the  position  of  the  ulcer 
and  the  conditions  associated  with  it,  especially  as  to  the 
presence  or  absence  of  adhesions  and  other  complications. 

Any  one  of  the  following  operations,  or  a  combination  of 
one  or  more,  may  be  called  for  in  each  individual  case  : 
Exploratory  gastrotomy ;  gastro  -  enterostomy,  to  secure 
physiological  rest  to  the  stomach  and  relieve  the  hyper- 
chlorhydria,  or,  in  other  cases,  to  short-circuit  a  stenosis ; 
excision  of  the  ulcer  ;  pylorectomy ;  pyloroplasty  ;  gastro- 
plasty ;  gastro-gastrostomy  ;  gastrolysis  ;  pylorodiosis  ;  gas- 
troplication. 

History. — The  first  operation  for  the  cure  of  ulcer  of  the 
stomach  was  performed  in  1881  by  Rydygier,  who  success- 
fully resected  a  large  ulcer  from  the  posterior  wall  of  the 
stomach. 

A  report  in  the  Centralhlatt  f.  Chir.,  No.  32,  1900,  states 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  iii 

that  a  woman  from  whom  he  excised  the  pylorus  in  1881, 
for  chronic  ulcer,  is  now  aged  forty-two  and  quite  well,  and 
that  she  has  since  borne  five  children.  A  similar  case  was 
treated  in  1881  by  \'an  Kleef.  A  3-ear  later — in  18S2 — 
Czerny  repeated  the  operation  successfully. 

After  other  cases  of  excision,  Doyen  in  1S93  introduced 
the  operation  of  gastro-enterostomy  for  the  treatment  of 
gastric  ulcer,  and  at  the  German  Congress  in  1895  he  related 
a  series  of  cases  in  which  he  attributed  the  relief  or  cure  of 
ulcer  of  the  stomach  by  gastro-enterostomy  to  the  rest 
induced  by  the  operation. 

Czerny,  Monod,  Durivier,  Kuster,  Xovaro,  Tricomi,  our- 
selves, and  many  others,  have  followed  on  the  same  lines. 

The  Preparation  of  tlie  Patient. — It  has  been  the  custom 
with  many  surgeons  to  put  stomach  patients  through  a  long 
course  of  preliminary  treatment,  such  as  frequent  lavage  of 
the  stomach  and  abstention  from  food  before  operation. 
This,  as  a  rule,  is  quite  unnecessary,  and  certainly  inad- 
visable in  the  greater  number  of  cases — first,  because  the 
treatment  is  depressing  and  debilitating  in  the  case  of 
patients  already  exhausted  by  a  long  illness ;  secondly,  as 
proved  by  Dr.  Harvey  Cushing"s  bacteriological  investiga- 
tions, the  stomach  contents  speedily  become  aseptic  if  the 
mouth  be  cleansed  and  aseptic  foods  administered ;  and, 
thirdly,  as  proved  by  ample  clinical  experience,  elaborate 
preliminary  treatment  is  unnecessary  to  success. 

If  the  stomach  is  greatly  dilated  and  the  contents  are  foul, 
then  lavage  with  simple  boiled  water  night  and  morning  is 
adopted  for  two  days  before  operation.  The  careful  cleans- 
ing of  the  mouth  and  teeth  and  the  administration  of  foods 
sterilized  by  boiling  is  advisable.  The  last  meal  is  given 
the  night  before,  about  twelve  hours  ;  the  stomach  is  washed 
out  about  two  hours,  and  a  nutrient  enema  given  about  an 
hour  before  operation. 

In  other  cases  no  lavage  is  adopted,  but  the  same  care  is 
exercised  in  cleansing  the  mouth,  giving  sterilized  food,  and 
administering  a  nutrient  enema  consisting  of  i  ounce  of 
brandy,  i  ounce  of  liquid  peptonoids,  and  10  ounces  of 
normal  saline   solution.      Ever}'  patient    is   enveloped   in   a 


112  SURGERY  OF  THE  STOMACH 

suit  of  cotton-wool  made  by  the  nurse  out  of  Gamgee  tissue, 
and  each  has  an  injection  of  lo  minims  of  liq.  strychnise 
(B.P.)  administered  subcutaneously  before  the  operation  is 
begun. 

The  preparation  of  the  skin  and  other  aseptic  details  of 
the  operation  differ  in  no  respect  from  those  observed  in 
operations  generall}'. 

Exploratory  Gastrotomy,  or  opening  the  stomach  by  a  free 
incision  in  its  anterior  wall,  is  an  operation  occasionally 
called  for  in  the  surgical  treatment  of  ulcer : 

(a)  In  order  to  verify  the  diagnosis  of  ulcer  when  there  is 
so  much  thickening  of  the  stomach  walls  as  to  suggest  the 
presence  of  cancer. 

(b)  When,  although  the  symptoms  have  pointed  to  ulcer 
as  the  cause  of  the  gastric  trouble,  the  stomach,  on  ex- 
posure, betra3'S  no  evidence  of  puckering  or  other  character- 
istic signs,  and,  in  order  to  verif}^  the  diagnosis  and  ascertain 
what  is  best  to  be  done,  it  is  felt  desirable  to  examine  the 
interior  of  the  organ. 

(c)  In  certain  cases  of  gastrorrhagia  it  is  desirable  to 
perform  explorator}^  gastrotomy,  in  order  to  find  and  liga- 
ture the  bleeding  vessels,  or  to  otherwise  arrest  the  haemor- 
rhage. 

{d)  It  necessarily  forms  part  of  any  operation  for  the 
excision  of  ulcer  of  the  stomach.  The  detailed  description 
of  the  operation  is  given  under  the  chapter  on  Gastrorrhagia 
and  its  Treatment,  p.  130. 

It  will  be  gathered,  on  reading  the  context,  that,  as  our 
experience  increases,  the  tendency  is  to  the  performance  of 
gastro-enterostomy,  without  previous  exploratory  gastrotomy, 
in  cases  of  ulcer. 

As  examples  of  exploratory  gastrotomy,  we  may  briefly 
refer  to  the  following  cases  : 

Man  aged  thirty-eight.  Symptoms  of  chronic  ulcer  extending 
over  several  years.  On  exposure  of  stomach,  no  evidence  on  the 
surface  to  indicate  accuracy  of  diagnosis.  Exploratory  gastro- 
tomy. Discovery  of  large  ulcer,  i|  inches  by  3  inches,  on 
posterior  wall  of  stomach.  Posterior  gastro-enterostomy.  Re- 
covery. 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  113 

Acute  gastrorrhagia.  No  evidence  of  ulcer  on  exposing  the 
stomach.  Exploratory  gastrotomy.  Numerous  bleeding  ulcers 
seen.  Two,  which  were  bleeding  freely,  were  ligatured  en  masse. 
Gastro-enterostomy.     Recovery. 

Excision  of  the  Ulcer  is,  as  a  rule,  unnecessary,  but  not 
always  to  be  avoided,  as  in  some  cases  of  bleeding  ulcer, 
and  in  others  where  the  thickening  and  induration  render  it 
difficult  to  decide  on  the  absence  of  malignant  disease. 
This  was  the  case  in  a  man  of  fifty-four  on  w^hom  }\Iayo 
Robson  operated  in  1891,  when,  finding  the  p3'lorus  the 
seat  of  diffuse  induration,  excision  of  the  whole  indurated 
area  was  performed  successfully.  A  careful  examination  of 
the  removed  mass  showed  that  the  growth  was  inflammatory 
around  a  chronic  ulcer.  In  another  middle-aged  man,  w^here 
the  diffuse  induration  was  suggestive  of  cancer,  the  pylorus 
w^as  opened,  and  a  deep  ulcer  on  the  posterior  w^all  success- 
fully excised,  the  edges  of  the  original  incision,  as  well  as  the 
margins  of  the  posterior  wound,  being  brought  together  in  a 
direction  transverse  to  the  axis  of  the  pylorus  over  a  bone 
bobbin,  as  in  the  modified  operation  of  gastro-enterostomy. 

Rydygier  prefers  excision  of  the  ulcer  to  gastro-enteros- 
tomy, because  he  believes  that  carcinoma  not  infrequently 
develops  in  the  scar  of  an  old  ulcer. 

It  is  impracticable  to  give  any  specific  description  of  the 
operation  of  excision  of  an  ulcer  other  than  wall  be  given  in 
the  description  of  operations  involving  the  removal  of  part 
of  the  stomach  wall,  seeing  that  the  procedure  will  vary  with 
the  size  and  position  of  the  ulcer. 

The  cases  related  below  sufficiently  exemplify  the  opera- 
tions that  may  be  necessary. 

After  excision  of  an  ulcer,  the  bleeding  from  large  vessels 
must  be  controlled  by  ligature,  but  the  oozing  from  the 
smaller  vessels  will  be  stopped  readily  by  the  continuous 
suture  employed  to  bring  together  the  edges  of  the  wound. 
If  the  excision  involve  the  serous  coat,  a  Lembert's  con- 
tinuous stitch,  w'ith  a  silk  or  celluloid  thread  suture,  will  be 
necessary.  Should  the  excision  have  been  near  the  pylorus, 
the  line  of  suture  must  be  placed  transversely  to  the  axis  of 
the  canal,  so  as  to  avoid  stricture. 


114  SURGERY  OF  THE  STOMACH 

The  following  cases  are  examples  of  gastric  ulcers  treated 
by  excision  : 

Ulcer  of  Pylorus  ;  Stenosis  ;   Dilatation  of  Stomach. 
Excision  of  Ulcer  and  Pyloroplasty. 

John  W.  R.,  aged  thirty-eight,  admitted  to  the  Leeds  In- 
firmary with  the  history  of  stomach  trouble  for  thirteen  years. 
Pain  after  food  and  vomiting  were  the  initial  symptoms.  Severe 
haematemesis  occurred  six  years  after  the  onset  of  symptoms. 
Great  loss  of  flesh  and  weakness  were  followed  by  inability  to 
work,  although  he  had  stomach  lavage  and  other  appropriate 
treatment.  On  admission,  the  patient  was  very  thin  and  pro- 
foundly weak.  He  weighed  8  stones.  An  indefinite  swelling 
could  be  felt  below  the  right  costal  margin.  The  stomach 
reached  3  inches  below  the  umbilicus,  and  there  was  visible 
peristalsis.  Free  HCl  present.  Operation  November  15,  1900. 
The  pylorus  was  found  much  thickened,  forming  a  hard  nodular 
swelling,  adherent  to  the  gall-bladder  and  liver,  and  to  the 
abdominal  wall  by  omental  adhesions.  After  separating  the 
adhesions,  a  small  perforation  was  discovered  in  front  of  the 
pylorus,  evidently  the  site  of  a  perforation  which  his  medical 
man,  who  was  present,  said  he  remembered  occurring  some 
months  previously,  and  which  was  then  treated  successfully  by 
rest  and  rectal  feeding. 

The  pylorus  was  freely  laid  open,  and  found  to  be  the  site  of  a 
round  perforating  ulcer  in  front,  and  another  in  the  posterior 
wall ;  the  latter  had  perforated  into  the  substance  of  the  pancreas. 
Both  were  resected,  the  removal  thus  practically  constituting  a 
pylorectomy.  The  edges  of  the  posterior  wound  were  brought 
together  transversely  to  the  axis  of  the  stomach.  The  anterior 
wound  was  prolonged  into  the  duodenum,  and  its  edges  were 
brought  together,  also  transversely  to  the  axis  of  the  stomach, 
over  a  bone  bobbin,  thus  leaving  a  capacious  channel  between 
the  stomach  and  duodenum  surrounded  by  healthy  mucous 
membrane. 

Recovery  was  uninterrupted,  and  he  was  discharged  on  De- 
cember 12,  weighing  8  stones  5  pounds. 

On  January  g,  iQoi,  he  returned  to  report  himself  well,  and 
then  weighed  g  stones  1 1  pounds. 

Pyloric  Ulcer  treated  by  Excision  of  Ulcer  and 
Pyloroplasty. 

Mrs.  M.  K.,  aged  forty-four.  Seen  by  Mayo  Robson,  with 
Dr.  Johnstone,  Ilkley.     Well  till  two  years  ago,  when  she  had 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  115 

colic  and  loss -of  flesh.  Under  treatment  she  recovered,  appar- 
ently, and  regained  some  of  the  lost  weight. 

Septemhev  15,  1897. — Recurrence  of  attacks  similar  to  that  of  a 
year  before,  but  with  pain  at  the  right  side  over  the  pylorus. 
Loss  of  weight  and  strength.  The  patient  had  for  some  time 
been  an  invalid,  and  had  been  continuously  under  medical  treat- 
ment for  months.  Her  weight  was  6  stones  1 1  pounds.  There 
was  visible  peristalsis  toward  the  pylorus,  which  was  fixed  to  the 
gall-bladder ;  no  pain  or  tenderness.  Liver  2  inches  below  costal 
margin,  but  not  nodular,  and  no  jaundice  present. 

July  23,  1898. — Operation.  An  ulcer  at  the  pylorus  adherent 
to  the  liver,  which  formed  the  base  of  the  ulcer ;  stenosis  of 
pylorus.  Pyloroplasty  performed  after  excision  of  ulcer,  the 
opening  being  sutured  transversely  over  a  bone  bobbin. 

December  3,  1898. — Had  gained  i  stone  8  pounds  in  weight. 
No  trouble  in  digesting  anything. 

December  23,  1899. — Dr.  Hearder  reports  patient  as  'very  well,' 
and  of  normal  weight. 

The  operation  of  Pylorectomy  for  ulceration  of  the  pylorus 
may  be  mentioned  under  the  heading  of  excision  of  ulcer, 
though  it  will  be  more  convenient  to  consider  this  operation 
in  detail  when  describing  partial  gastrectomy  for  cancer, 
seeing  that  the  operation  for  the  two  conditions  is  essentially 
the  same.  Dr.  Rodman  {Philadelphia  Medical  Journal,  June  9, 
igoo)  has  collected  from  literature  and  personal  correspon- 
dence detailed  reports  of  forty  pylorectomies,  partial  gastrec- 
tomies and  excisions,  with  six  deaths.  As  this  includes  cases 
since  1881,  when  Rydygier  performed  the  first  excision  of 
ulcer,  it  does  not  show  the  operation  under  a  favourable 
light,  the  mortality  being  15  per  cent. ;  for  it  would  be  found 
that  the  later  operations  under  improved  technique  contrast 
favourably  with  the  earlier  ones.  One  of  us — Mayo  Robson 
— has  performed  the  operation  of  excision  of  gastric  ulcer  six 
times,  all  the  patients  recovering. 

Nevertheless,  the  mortality  after  excision  will  probably 
always  be  higher  than  the  more  simple  operation  of  gastro- 
enterostomy, with  its  5  per  cent,  or  smaller  mortality.  The 
more  severe  and  radical  operation  should  therefore  be  reserved 
for  cases  that  are  not  suitable  for  the  less  severe  operation, 
or  for  cases  in  which  the  suspicion  of  cancerous  degeneration 

8—2 


ii6  SURGERY  OF  THE  STOMACH 

is  entertained,  and  cannot  be  disproved  on  naked-eye  inspec- 
tion. 

The  following  case  is  an  example  : 

Tumour  of  Pylorus  and  Chronic  H^matemesis  due  to 
Ulcer.     Pylorectomy. 

In  1 891  one  of  us  (A.  W.  M.  R.)  was  asked  by  a  medical  friend 
to  see  a  man  of  fifty-four,  who  for  six  months  had  suffered  from 
pain  coming  on  an  hour  after  food,  and  more  recently  from  vomit- 
ing of  blood  of  coffee-ground  character  in  considerable  quantities, 
so  that  he  was  not  only  reduced  in  flesh  and  strength,  but  had 
also  been  rendered  profoundly  anaemic  by  the  loss  of  blood. 

A  tumour  of  the  pylorus  could  be  easily  felt,  and  the  stomach 
was  markedly  dilated. 

As  he  was  rapidly  losing  ground,  an  operation  was  performed, 
and  the  pylorus  found  thickened  and  nodular,  with  adhesions  to 
the  liver  and  omentum.  After  separating  the  adhesions,  the 
pylorus  was  excised,  and  the  open  end  of  the  duodenum  was  fixed 
to  the  opening  in  the  stomach  by  means  of  two  lines  of  sutures 
without  the  use  of  a  bobbin,  the  rest  of  the  stomach  aperture 
being  closed  by  a  double  layer  of  sutures. 

The  tumour  proved  to  be  inflammatory  around  an  open  ulcer 
which  had  been  the  source  of  the  haemorrhage.  The  bleeding 
was  not  repeated,  and  the  patient  rapidly  gained  flesh,  and  re- 
turned home  within  the  month. 

The  subsequent  history  of  this  case  is  interesting  on  account 
of  cicatricial  contraction  of  the  new  pyloric  aperture,  which 
led  to  the  invention  and  employment  of  a  decalcified  bone 
bobbin  to  act  as  a  temporary  splint  upon  which  to  apply  the 
sutures,  and  so  secure  a  large  aperture  which  has  little 
tendency  to  contract. 

Gastro-enterostomy,  in  the  absence  of  special  complications, 
is  the  operation  to  be  relied  on  in  the  treatment  of  ulcer  of 
the  stomach  ;  it  acts  by  securing  physiological  rest  by  means 
of  drainage,  thus  allowing  the  ulcer  to  heal  without  being 
subjected  to  the  irritation  of  acid  secretion,  accumulation  of 
food,  or  frequent  stomach  movement.  It  also,  while  remedy- 
ing the  hyperchlorhydria,  relieves  pyloric  spasm,  and  while 
preventing  stagnation  of  fluids,  cures  or  materially  dimin- 
ishes gastric  dilatation.  The  posterior  operation  is  the  one 
we  personally  prefer,  the  junction  of  the  posterior  wall  of  the 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  117 

stomach  with  the  first  part  of  the  jejunum  being  effected  by 
two  continuous  sutures  with  or  without  a  decalcified  bone 
bobbin.  The  use  of  a  bone  bobbin  not  only  secures  a  tem- 
porary protection  to  the  line  of  incision,  but  secures  an  ample 
and  immediately  patent  opening  between  the  two  viscera 
for  the  passage  of  the  stomach  contents.  The  whole  opera- 
tion can  be  easily  completed  in  half  an  hour,  and  it  may  even 
be  done  in  half  the  time. 

Our  experience  with  the  posterior  operation  has  been  very 
favourable,  not  only  in  the  rate  of  recovery  of  the  patients, 
but  in  the  smoothness  of  the  recovery,  many  of  the  patients 
recovering  without  even  once  vomiting  ;  and  only  on  two 
occasions  have  we  seen  slight  regurgitant  vomiting  of  bile, 
which  in  the  anterior  operation  is  much  more  frequently 
seen,  and  at  times  becomes  serious,  or  even  leads  to  a  fatal 
issue. 

We  have  performed  the  operation  on  forty  patients  with 
two  deaths,  or  an  average  mortality  of  5  per  cent. ;  but  as 
the  deaths  were  from  more  or  less  accidental  causes,  which 
should  be  avoided  in  the  future,  and  occurred  respectively  on 
the  tenth  and  eleventh  days  after  operation,  during  the  whole 
of  which  time  the  patients  had  been  able  to  take  and  assimi- 
late food,  the  gastro-enterostomy  per  se  cannot  be  blamed 
for  the  fatal  result,  which  might  under  similar  circumstances 
have  occurred  after  any  operation.  Under  the  description 
of  the  operation  of  gastro-enterostomy  will  be  found  a  brief 
resume  of  ail  the  cases  on  which  we  have  operated. 

A  detailed  description  of  the  operation  of  gastro-enter- 
ostomy and  its  modifications  will  be  found  on  p.  268. 

Dr.  Fantino  {Archiv.  fur  Klinische  Chirurgie,  Bd.  xlvi.,  i 
and  2)  examined  Professor  Carle's  cases  of  gastro-enteros- 
tomy as  regards  the  following  points  : 

1.  Changes  in  the  peristalsis  of  the  stomach. 

2.  The  ability  or  non-ability  of  the  new  sphincters  to  close 
the  outlet, 

3.  The  capacity  of  the  stomach. 

4.  The  secretion  of  hydrochloric  acid. 

In  the  cases  examined,  the  operation  immediately  improved 
the  peristaltic  power  of  the  stomach,  though  it  did  not  render 


ii8  SURGERY  OF  THE  STOMACH 

it  normal.  The  stomach  could  generally  empty  itself,  but 
did  so  graduall}'.  Systematic  examinations  of  the  stomach 
contents  were  made  after  test-meals,  etc.,  and  showed  that 
after  an  irregular  period  the  stomach  regained  completely  its 
power  of  emptying  itself;  in  fact,  as  a  rule,  after  gastro- 
enterostomy the  stomach  would  be  found  practically  empty 
in  three  to  five  hours  after  a  meal. 

Generally  it  was  found  that  the  stomach  decreased  in  size 
soon  after  gastro-enterostom}^,  so  that  the  formerly  distended 
organ  became  normal  in  size.  Examination  of  the  stomach  by 
means  of  distension  with  carbonic  acid  and  by  other  methods 
showed  that  a  sphincter  was  developed  at  the  new  opening, 
and  that  its  power  increased  with  time.  The  secretion  of 
hydrochloric  acid  after  operation  was  studied.  In  cases 
where  there  was  formerly  hyperacidity  this  condition  was 
lost,  and  though  the  degree  of  acidity  in  an  individual  case 
varied  from  time  to  time,  yet  these  variations  did  not  depart 
from  physiological  limits.  In  the  same  examinations  it  was 
found  that  regurgitation  of  bile  into  the  stomach  took  place, 
but  it  was  of  no  importance  so  long  as  the  outlet  from  the 
organ  was  sufficient.  Cases  of  hypo-  and  anacidity  showed 
no  change  in  their  gastric  juice  after  operation,  showing 
clearly  that  this  condition  is  not  dependent  on  obstruction, 
but  on  previous  changes  in  the  mucous  membranes,  these 
changes  being  probably  in  the  nature  of  an  atrophy  of  the 
peptogastric  glands. 

The  following  cases  are  given  as  examples  : 

Case  i. — Mrs.  W.,  aged  thirty-two.  Pyloric  ulcer  treated  by 
pyloroplasty,  with  subsequent  contraction.  Gastro-enterostomy 
(anterior).  Seen  by  A.  W.  M.  R.,  with  Dr.  Salter  of  Scar- 
borough. Pyloroplasty  during  active  ulceration  of  pylorus  in 
December,  1895.  Great  relief  for  a  time,  but  later  recurrence  of 
dilatation,  vomiting,  pain,  and  other  symptoms.  Very  consider- 
able loss  of  flesh.  Patient  thin  and  ancemic  ;  pulse  feeble  and 
rapid,  marked  dilatation,  the  stomach  reaching  well  below  the 
umbilicus. 

October  4,  i8g8. — Operation  :  gastro-enterostomy  (bone  bobbin 
employed). 

In  October,  1899,  patient  well  and  active. 

February,  1900,  had  gained  i  stone  10  pounds. 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  119 

Case  2. —  Mr.  M.  A.,  aged  twenty-eight.  Pyloric  ulcer,  tumour 
of  pylorus.  Gastro-enterostomy  (anterior).  Seen  by  A.  W.  M.  R., 
with  Dr.  Kilner  Clarke  of  Huddersfield.  Loss  of  weight.  Two 
years  ago  was  12  stones  12  pounds  ;  now  9  stones  6  pounds.  Pain 
two  hours  after  food.  For  last  two  months  vomiting  on  an  average 
five  times  a  week — twice  coffee-grounds.  Enormous  dilatation 
of  stomach.     Pyloric  tumour  movable  ;  visible  peristalsis. 

August  4,  1899. — Operation.  Large  mass  at  pylorus,  evidently 
thickening,  due  to  active  ulceration ;  glands  large,  but  not  matted. 
Gastro-enterostomy  (bone  bobbin  used). 

August  27,  1899. — Good  recovery.     Weighs  g  stones  7  pounds. 

September  20,  1899. — Weighs  10  stones  13  pounds.  Can  eat 
anything. 

Well  1 90 1. 

Case  3. — Mr.  D.  B.,  aged  thirty-one.  Extensive  ulceration 
of  stomach,  with  large  tumour.  Gastro-enterostomy  (anterior). 
Seen  by  A.  W.  M.  R.,  with  Dr.  Barrs  and  Dr.  Webster,  Golcar. 
Dyspepsia  seventeen  years  ;  more  severe  last  twenty  months. 
Lead-poisoning  discovered  and  treated.  Good  recovery.  Six- 
teen months  ago  vomiting  recurred,  and  from  outset  large  quanti- 
ties ejected,  but  never  containing  blood.  Recurrence  occasionally 
of  similar  attacks,  always  relieved  by  treatment. 

December,  1897. — Stomach  reached  pubes,  and  visible  peristalsis 
seen.  Relief  followed  dieting  and  lavage  till  March,  1898,  since 
which  time  pain  almost  constant.  Pain  not  materially  worse  after 
food  nor  relieved  by  vomiting.  Loss  of  weight  from  10  stones 
to  8  stones  6^  pounds.     Great  feebleness. 

May  6,  1898.— Operation.  Large  irregular  tumour  at  pylorus 
and  along  lesser  curvature  ;  but  glands,  though  large,  discrete. 
Gastro-enterostomy  (bone  bobbin  employed). 

June  7,  1898. — 8  stones  in  weight  when  he  left  the  home. 

Augttst  17,  1898. — Weighs  9  stones  3  pounds. 

Letter  dated  February  12,  1900  :  '  My  health  continues  perfect. 
I  have  not  lost  a  day's  work  through  illness  since  I  recovered.' 

Examples  of  posterior  gastro-enterostomy  : 

Case  4. — Miss  H.,  thirty-two,  sent  to  i\Iayo  Robson  by  Dr. 
Angus  of  Bingley  with  a  history  of  stomach  symptoms  extend- 
ing over  several  years.  She  had  had  hsematemesis  in  1892  and 
1896,  since  which  time  she  had  suffered  from  flatulency  and  pain 
after  food.  For  two  years  epigastric  pain  constant,  but  increased 
by  food.  A  year  after  A'omited  daily,  then  relief  for  a  time  ;  but 
for  some  months  only  milk  could  be  retained. 

Epigastric  tenderness  was  well  marked,  and  in  distending  the 


I20  SURGERY  OF  THE  STOMACH 

stomach  with  CO.,  it  reached  \  inch  below  the  umbiHcus  and  far 
over  to  the  right  of  the  middle  line. 

October  5,  1900.  —  Posterior  gastro-enterostomy  performed,  a 
bone  bobbin  being  employed. 

Recovery  uninterrupted.  Returned  home  within  the  month, 
taking  solid  food  without  any  discomfort  and  gaining  flesh. 

On  November  8  Dr.  Angus  wrote  :  '  I  have  seen  Miss  H. 
since  her  return,  and  there  is  every  reason  to  be  pleased  with  her 
condition.  She  has  lost  all  her  pain  and  is  taking  food  well. 
Allow  me  to  thank  you  for  her  restoration  to  comparative  health.' 

Weight  February,  1901,  8  stones  6  pounds;  at  time  of  opera- 
tion, 6  stones  12  pounds. 

Case  5. — Mr.  H.,  aged  fifty-two,  sent  to  Mayo  Robson  by 
Dr.  Hearder  of  Ilkley,  began  to  suffer  in  1897  from  symptoms 
of  ulcer  of  stomach,  which  were  relieved  by  restricted  diet  and 
general  treatment  ;  but  in  July,  1899,  the  symptoms  returned, 
with  loss  of  flesh,  and  well-marked  dilatation  of  the  stomach  was 
discovered,  and  operative  treatment  advised. 

Lavage  and  other  treatment  was  carried  out  in  London  and 
in  Scotland,  but  without  material  improvement. 

When  first  seen  by  us  there  was  visible  peristalsis,  with  well- 
marked  stomach  splash  and  a  tender  spot  under  the  right  costal 
margin.  Although  tall,  the  patient  only  weighed  8  stones  6  pounds, 
and  he  was  extremely  weak  and  pallid.  Free  HCl  was  discovered 
in  the  stomach  contents. 

October  12,  1900. — Hour-glass  contraction  found,  but  the  con- 
striction was  not  extreme.  Puckering  on  anterior  wall  of  stomach, 
with  well-marked  thickening.  Posterior  gastro-enterostomy  per- 
formed.    Good  recovery. 

March  4,  1901.  —  Patient  wrote  from  Bournemouth  saying: 
'  I  am  pleased  to  be  able  to  tell  you  that  I  have  no  return  of  my 
former  complaint,  and  that  I  eat,  drink,  and  sleep  well.  Have 
got  back  to  my  former  weight. 

Case  6. — History. — J.  S.,  aged  forty-five,  residing  at  Batley, 
gave  the  history  of  two  years'  pain  about  an  hour  after  food,  with 
great  loss  of  flesh.  For  nine  months  he  had  vomited  every  day, 
or  every  second  day,  a  large  quantity  of  yeasty  material,  but  no 
blood,  though  he  was  very  anaemic. 

There  were  well-marked  signs  of  dilatation,  with  tenderness 
over  the  pylorus. 

June  12,  1900. — Operation.  On  opening  the  abdomen  the  pylorus 
was  much  thickened  and  adherent,  forming  a  tumour,  and  through 
the  centre  of  the  mass  a  No.  10  catheter  could  only  be  passed  over 
a  roughened,  ulcerated  surface.  A  posterior  gastro-enterostomy 
was  performed. 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  121 

After -history. — An  uninterrupted  recovery  followed.  Food  was 
begun  the  second  day,  and  solids  could  be  taken  in  the  second 
week  without  pain.  He  rapidly  gained  flesh  and  strength,  and 
is  now  well. 

Demoulin  and  Tuffier  {Btill.  et  Mem.  de  la  Soc.  de  Cliir.  de  Paris, 
October  31,  1899,  and  British  Medical  Journal,  SuppL,  1899) 
publish  the  case  of  a  naval  Lieutenant,  aged  thirty-two,  who 
suffered  from  severe  dyspeptic  symptoms  early  in  1897,  ^.ggra- 
vated  by  a  diet  of  preserved  meat  during  a  cruise  round  the  coast 
of  Ireland.  Early  in  1898  a  hard  swelling  developed  in  the 
epigastrium.  Medical  treatment  at  Vichy  and  elsewhere  was  of 
no  avail.  His  weight  fell  to  77  pounds,  the  cachexia  was  marked, 
and  emaciation  extreme.  The  swelling  was  as  big  as  an  orange, 
movable  transversely,  and  following  respiratory  movements.  It 
was  tough  rather  than  hard.  Directly  the  patient  swallowed 
anything,  even  a  few  spoonfuls  of  water,  great  distension  of  the 
epigastrium,  with  severe  pain,  occurred,  due  evidently  to  contrac- 
tion of  the  stomach  for  forcing  its  contents  through  the  pylorus. 
Malignant  tumour  was  diagnosed,  and  Demoulin  operated  on 
December  i,  1899.  An  incision  4  inches  long  was  made  in  the 
middle  line  above  the  umbilicus.  A  soft  tumour  of  the  size  of 
an  orange  lay  around  the  pylorus  and  adjacent  parts  of  the 
stomach  and  duodenum.  It  felt  like  a  fatty  growth,  and  was  not 
adherent  to  any  surrounding  structures.  A  stellate  cicatrix  on 
its  upper  aspect  showed  signs  of  a  healing  ulcer.  There  were  no 
enlarged  glands  in  the  neighbouring  peritoneal  folds ;  the  liver 
and  gall-bladder  were  healthy.  The  patient  was  in  so  exhausted 
a  condition  that  a  pylorectomy  was  considered  impracticable. 
Demouhn  therefore  performed  a  Van  Hacker's  gastro-enteros- 
tomy  (posterior  and  transmesolic),  leaving  the  tumour  alone.  A 
litre  of  salt  solution  was  injected  under  the  skin  directly  after  the 
operation.  The  patient's  life  was  in  great  peril  for  several  days 
from  ether  bronchitis.  On  the  third  day  haematemesis  occurred, 
and  nearly  a  pint  of  blood  was  vomited.  By  the  loth  the  patient 
was  able  to  eat  fish  and  fowl  without  any  bad  effects.  On  the 
2oth  Demoulin  for  the  first  time  palpated  the  epigastrium.  To 
his  surprise,  the  tumour  could  no  longer  be  felt,  its  site  being 
marked  by  a  little  thickening,  which  vanished  within  ten  days. 
In  May  the  patient  was  again  on  active  naval  service  ;  no  local 
symptoms  remained,  but  he  was  troubled  with  an  obstinate  cough 
and  free  expectoration. 

Bowreman  Jessett  has  recently  described  a  somewhat 
similar  case  {British  Medical  Journal,  April,  1901). 

Pyloroplasty  will  be  more  fully  described  when  the  subject 


122  SURGERY  OF  THE  STOMACH 

of  pyloric  stenosis  is  under  consideration,  but  we  must  not 
fail  to  mention  it  as  a  method  of  treatment  in  certain 
cases  of  chronic  ulcer  associated  with  stenosis  of  the 
pylorus.  The  operation  as  a  curative  measure  in  this  class 
of  cases  has  certain  very  definite  limitations,  but  where  it  is 
feasible  it  is  a  method  of  great  utility,  which  can  be  per- 
formed rapidly  and  with  very  little  exposure  of  viscera. 
Pyloroplasty,  if  the  pylorus  be  stenosed,  free  from  extensive 
adhesions,  easily  drawn  forward,  and  not  actively  ulcerating, 
is  a  simple  and  short  operation,  and  in  quite  a  number  of 
cases  of  both  gastric  and  pyloric  ulcer  we  have  found  it 
to  answer  well.  It  must  not  be  relied  on,  however,  where 
active  ulceration  of  the  pylorus  itself  is  found,  unless  at 
the  same  time  the  ulcer  be  completely  excised ;  otherwise 
cicatricial  contraction  will  occur,  and  a  second  operation 
will  be  subsequently  required.  It  acts  in  the  same  way 
as  does  gastro-enterostomy,  by  affording  a  free  exit  to  the 
stomach  contents,  and  thus  securing  physiological  rest  to 
the  stomach. 

The  following  cases  exemplify  the  complete  success  which 
attended  the  operation  in  appropriate  conditions,  and  also 
the  disappointment  which  followed  its  employment  in  one  of 
the  earlier  cases,  w^hich,  owing  to  inexperience,  w^as  not 
properly  selected. 

Professors  Carle  and  Fantino  (loc.  cit.)  compare  the  opera- 
tions of  gastro-enterostomy  and  pyloroplasty.  Out  of  fourteen 
cases  in  which  the  latter  operation  was  performed,  only  one 
died.  The  results  of  pyloroplasty,  as  regards  function,  have 
been  little  noticed  in  literature.  To  the  authors'  fourteen 
cases,  three  may  be  added  where  the  operation  was  by 
tearing,  but  the  results  were  the  same.  In  all  the  seventeen 
cases  the  results  were  excellent — in  thirteen  of  them  perfect 
and  permanent,  as  it  is  now  from  three  to  seven  years  since 
operation.  In  these  the  condition  of  the  secretions  and  of 
the  peristaltic  power  of  the  stomach  were  the  same  as  after 
gastro-enterostomy  for  non-malignant  stenosis.  Diminution 
in  size  of  the  stomach  was  not  so  marked  as  would  be 
expected  in  the  presence  of  such  remarkable  recovery  of  the 
general  health  and  of  the  stomach's  power  to  empty  itself.    In 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  123 

all  cases,  with  one  exception,  the  gastric  capacity  was  more 
or  less  diminished,  but  in  no  case  did  it  become  normal  in 
size. 

A  few  cases  must  be  excepted  where  operation  was  per- 
formed for  hyperacidity,  with  gastric  atony.  In  these,  four 
to  five  months  after  operation,  there  was  delayed  evacuation 
of  the  stomach  and  a  feeling  of  weight.  Although  the 
general  improvement  was  considerable,  yet  the  authors  were 
persuaded  that  a  posterior  gastro-enterostomy  would  have 
given  better  results.  In  one  of  the  cases  a  subsequent 
gastro-enterostomy  gave  a  perfect  recovery. 

In  cases  where  there  was  hyperacidity  before  the  operation, 
there  was  a  rapid  return  to  the  normal,  but  not  to  below 
normal,  as  we  found  after  gastro-enterostomy.  The  authors 
believe  that  the  rapid  and  great  diminution  in  hydrochloric 
acid  after  the  latter  operation  is  due  to  the  very  rapid 
evacuation  of  the  stomach  after  a  meal,  and  do  not  deny  the 
possible  influence  of  a  regurgitation  of  bile  into  the  stomach. 
Both  these  conditions  are  absent  after  pyloroplasty ;  hence 
the  difference  in  secretion. 

In  cases  of  hypo-  and  anacidity,  operation  produced  no 
change  in  this  particular,  and  yet  health  was  restored.  The 
results  of  pyloroplasty  may  be  summarized  : 

1.  Regurgitation  of  bile  into  the  stomach  is  prevented. 

2.  Secretion  of  hydrochloric  acid,  when  it  has  been  exces- 
sive, becomes  normal. 

3.  If  the  secretion  of  hydrochloric  acid  has  been  diminished 
or  absent  before  operation,  it  remains  in  static  quo  after 
operation. 

4.  If  there  has  been  primary  gastric  atony,  peristalsis  is 
but  little  improved. 

5.  This  function  improves  rapidly  or  reaches  perfection  if 
the  muscular  contractility  has  been  normal  or  increased,  and 
when  the  obstruction  was  due  to  fibrous  stenosis  or  pyloric 
spasm. 

6.  In  all  such  cases  evacuation  of  the  stomach  is  accom- 
plished in  its  physiological  period.  Only  in  rare  cases,  and 
these  only  in  the  first  months  after  operation,  may  it  be 
delayed. 


124  SURGERY  OF  THE  STOMACH 

7.  The  capacity  of  the  stomach  always  decreases,  but 
rarely  becomes  as  small  as  normal. 

8.  The  pylorus  recovers  tone. 

Points  of  difference  between  the  results  of  pyloroplasty 
and  gastro-enterostomy  are : 

1.  The  absence  of  regurgitation  of  bile,  and  hence  the 
absence  of  any  possible  biliary  influence  on  the  gastric 
secretions. 

2.  The  evacuation  of  the  stomach  is  not  accelerated ; 
hence  the  difficulty  the  stomach  has  in  reaching  its  normal 
size. 

3.  The  slight  or  negative  result  obtained  by  pyloroplasty 
in  obstruction  from  primary  gastric  atony  compared  to  the 
positive  results  from  posterior  gastro-enterostomy. 

Pyloroplasty  is  too  dangerous  in  cases  where  there  are 
extensive,  severe  hardening  of  the  tissues,  much  peripyloritis, 
and  adhesions  to  liver,  gall-bladder,  colon,  etc.,  and  in  cases 
of  duodenal  stenosis.  It  is  indicated  in  cases  of  spasmodic 
stenosis,  and  in  slight  annular  stenoses  from  ulceration 
accompanied  by  muscular  hypertrophy. 

Statistics. — In  the  Hunterian  Lectures  we  collected  318 
cases  of  pyloroplasty  from  all  sources,  of  which  269  re- 
recovered,  which  equals  a  mortality  of  15*4  per  cent.  This 
included  14  cases  of  Mayo  Robson's,  of  which  12  recovered 
— a  mortality  of  I4'2  per  cent.  As  in  the  earlier  opera- 
tions many  were  performed  on  cases  that  would  be  now 
treated  by  gastro-enterostomy,  the  mortality  in  properly- 
selected  cases,  we  think,  should  not  exceed  5  per  cent,  at  the 
outside  estimate,  and  of  the  12  cases  operated  on  by  Mayo 
Robson  since  1897  there  is  no  fatality  to  record. 

Case  i. — March  9,  1895. — Mrs.  W.,  aged  twenty-nine.  Seen 
by  Mayo  Robson  with  Dr.  S.  '  Spasms '  for  ten  years,  but 
pain  more  on  left  side.  Attacks  two  or  three  times  a  week  ; 
start  without  apparent  reason,  last  an  hour  or  two,  but  may 
persist  twenty-four  hours,  relieved  by  vomiting.  Severe  cramp 
in  legs,  loss  of  2  stones  in  weight,  no  jaundice,  marked  constipa- 
tion. Rigid  right  rectus ;  no  rigidity,  but  tenderness  to  left. 
Dilatation  of  stomach  well  marked. 

November  22,   1895. — Relief  under  treatment,  followed  by  re- 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  125 

lapse ;  now  vomiting  daily.  Weight  9  stones.  Operation.  Ad- 
hesions of  pylorus  separated.  Active  ulceration  at  pylorus  and 
tight  stricture.     Pyloroplasty  (bone  bobbin). 

July  24,  1897. — Weight  g  stones  5  pounds,  very  much  better. 
Relapse  in  1898,  possibly  from  recurrence  of  ulceration.  We 
then  performed  gastro-enterostomy.  Quite  well  in  1900,  and 
former  weight  fully  regained. 

Case  2. — January  13,  1897. — Mr.  M.  B.,  aged  fifty-two. 
Ulcer  of  pylorus,  with  stricture.  Pyloroplasty.  Seen  by  Mayo 
Robson  with  Dr.  Wilks,  Grassington.  Bad  health  for  twenty 
years,  with  dyspepsia.  Enteric  fever  nine  years  ago.  Last  two 
years  much  worse — pain,  sickness,  and  vomiting  two  to  three 
hours  after  meals,  relieved  by  vomiting  of  large  amounts.  Never 
vomited  blood.  Loss  of  flesh.  W^eight  9  stones  3  pounds. 
Emaciation,  dilatation  of  stomach.  No  tumour.  Operation. 
Stricture  of  pylorus.     Pyloroplasty  (bone  bobbin  used). 

September  19,  1898. — Dr.  Wilks  writes  :  'For  some  time  little 
improvement ;  stomach  now  works  well.  Looks  better  than  I 
have  ever  seen  him.'  Well  February,  1901.  Has  gained  normal 
weight. 

Case  3. — March  18,  1897. — Mrs.  W.,  aged  forty-six.  Stric- 
ture, with  active  ulceration  at  pylorus.  Pyloroplasty.  Seen  by 
Mayo  Robson  with  Dr.  Drake,  Headingley.  Gastralgia  for 
several  years,  relieved  by  food.  In  November,  1894,  vomited 
dark  fluid  ;  since  then  frequent  vomiting,  longest  interval  two  or 
three  weeks.  Pain  in  stomach,  accompanied  by  hard  lump,  and 
often  followed  by  vomiting.     Great  loss  of  flesh  and  strength. 

Operation.  Pyloroplasty  for  contraction  and  thickening  of 
pylorus,  passage  only  admitting  a  No.  12  catheter.  Good 
recovery.     Well  1899.     Considerable  gain  in  weight. 

Case  4. — May  24,  1897. — Mr.  H.,  aged  thirty-nine.  Seen 
by  Mayo  Robson  with  Dr.  Matheson,  Sheffield.  Letter  dated 
May  13,  1897,  to  say:  'During  the  last  eighteen  months  I  have 
suffered  much  pain,  which  has  caused  me  to  be  bed-fast  for  two, 
three,  or  four  weeks  at  a  time,  and  it  has  required  another  month 
or  more  for  me  to  gain  strength  enough  to  move  about.'  Eighteen 
months  ago  epigastric  pain  several  hours  after  food,  relieved  by 
vomiting.  Since  then  health  never  good ;  three  and  a  half 
months  ago  similar  attack,  very  severe,  with  collapse.  Vomit 
contained  blood.  Fourteen  days  ago  another  severe  attack. 
Normal  weight  10  stones  10  pounds  ;  now  9  stones  22  pounds. 
Stomach  '  weak '  since  childhood.  Marked  dilatation.  No 
tumour. 

Operation.  Deep  ulcer  at  pylorus.  Extreme  stricture,  barely 
admitting  ordinary  director.      Pyloroplasty  (bone  bobbin  used). 


126  SURGERY  OF  THE  STOMACH 

Complete  recovery  from  operation,  and  rapidly  regained  normal 
weight.  Letter  dated  February  i6,  1898,  to  say:  '  I  thought  you 
would  like  to  know  that  I  am  able  to  attend  business  as  usual, 
and  have  done  so  without  interruption  since  July  ig,  1897.' 

Case  5. — July  12,  1897. — Mrs.  W.,  aged  forty-six.  Seen  by 
Mayo  Robson  with  Dr.  Johnson,  Aysgarth.  Said  to  have  had 
ulcer  of  stomach  twenty  years  ago.  Since  then  subject  to  attacks 
of  pain  half  to  two  hours  after  food  ;  sometimes  continuous  pain. 
For  three  or  four  months  vomiting  three  times  a  day.  Lost  a 
stone  weight  in  that  time.  Leading  life  of  an  invalid,  and  for  a 
long  period  under  medical  treatment  without  benefit.  Dilatation 
of  stomach  ;  visible  peristalsis  ;  tenderness  over  stomach,  espe- 
cially at  the  pylorus.     No  tumour  could  be  felt. 

Operation.  Stomach  much  dilated  ;  thickening  at  pylorus. 
Pyloroplasty  (bone  bobbin  used). 

Good  recovery.  Weighed  11  stones  January  8,  1898,  a  gain  of 
over  2  stones. 

Case  6. — July  27,  1897. — Mr.  C,  aged  twenty-three.  Seen  by 
Mayo  Robson  with  Dr  Percival  and  Dr.  Barrs.  Vomiting  and 
loss  of  flesh  for  two  years.  Was  10  stones ;  now  is  7  stones  in 
weight.  Dieting  and  lavage  give  only  temporary  relief.  Emacia- 
tion, pallor,  dilatation  of  stomach.     No  tumour. 

Operation.  Much-contracted  pylorus,  great  hypertrophy,  the 
walls  more  than  ^  inch  thick.  Pyloroplasty  with  bone  bobbin. 
Good  recovery. 

December  23,  1897. — Weight  9  stones  2  pounds.     Well. 

Case  7. — W.  F.,  aged  fifty-two,  was  sent  to  Mayo  Robson  by 
Dr.  Cheesewright,  of  Rotherham,  in  March,  1895.  ^^  had 
suffered  from  indigestion  for  two  years.  This,  however,  had  not 
interfered  much  with  his  general  health  till  the  previous  Christ- 
mas, when  the  indigestion  was  accompanied  every  second  day  by 
acute  pain  and  vomiting,  coming  on  about  two  hours  after  food. 
The  vomited  matter  was  in  large  quantity,  offensive  and  sour, 
and  at  times  coffee-ground  in  character.  From  this  time  the 
patient  became  extremely  weak  and  pale,  and  rapidly  lost  flesh 
to  the  extent  of  i-i-  stones  in  five  weeks.  He  had  no  previous 
history  of  severe  illness  nor  did  his  family  history  denote  heredi- 
tary tendency  to  disease.  Patient  extremely  emaciated,  anaemic, 
and  weak  ;  tongue  coated  and  bowels  constipated.  He  had  pain 
on  pressure  over  the  pylorus,  but  no  distinct  tumour  was  felt. 
There  was  marked  dilatation  of  the  stomach,  and  during  the 
attacks  of  pain  it  could  be  felt  to  harden  under  the  hand.  Heart, 
lungs,  and  urine  normal.  Our  feeling  was  that,  on  account  of 
the  very  rapid  loss  of  flesh,  accompanied  by  cachexia,  the  patient 
was  suffering  from  cancer  of  the  pylorus.     Operation  was  advised 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  127 

with  a  view  to  performing  pyloroplasty  or  pylorectomy,  as  cir- 
cumstances demanded,  since  washing  out  the  stomach  and  all 
ordinary  medical  means  had  given  no  relief. 

On  April  8,  1898,  the  abdomen  was  opened  by  an  incision  in 
the  middle  line  above  the  umbilicus,  exposing  the  pylorus,  which 
formed  a  distinct  tumour  adherent  to  and  under  cover  of  the 
liver,  and  which,  after  being  freed  from  adhesion  to  surrounding 
structures,  was  found  to  be  tightly  strictured,  so  as  only  to  admit 
the  passage  of  a  No.  12  catheter,  the  mucous  membrane  being 
extensively  ulcerated  and  the  walls  thick  and  almost  cartilaginous. 
The  stricture  was  incised  longitudinally  and  sutured  transversely 
over  a  bone  bobbin  by  a  double  row  of  sutures.  The  stomach 
was  much  dilated,  atonic,  and  anaemic.  Though  the  pyloric 
tumour  gave  rise  at  the  moment  to  a  suspicion  of  cancer,  there 
was  no  evidence  of  growth  and  the  glands  w^ere  not  affected. 
The  after-progress  of  the  case  was  uneventful,  the  wound  healing 
by  first  intention,  A  month  later  he  had  gained  7  pounds  in 
weight,  and  on  October  30,  1896,  he  called  to  report  himself, 
looking  robust  and  well.  He  had  gained  3  stones  in  weight  since 
his  operation. 

Gastroplasty  is  an  operation  that  we  have  successfully  em- 
ployed in  a  number  of  cases  of  chronic  ulcer  of  the  stomach 
leading  to  hour-glass  contraction.  The  operation,  which  can 
be  performed  in  several  ways,  will  be  fully  described  in  the 
chapter  dealing  with  that  deformity  of  the  stomach. 

It  consists  in  making  a  longitudinal  incision  through  the 
strictured  part  of  the  stomach  and  bringing  the  edges  of  the 
wound  together  transversely,  thus  obliterating  the  stricture. 
A  convenient  method  of  performing  the  operation  is  by  the 
use  of  a  large  decalcified  bone  bobbin,  as  described  in  the 
cases  appended  to  the  chapter  on  hour-glass  contraction. 

If  the  strictured  part  of  the  stomach  be  actively  ulcerat- 
ing, as  in  a  case  related  elsewhere,  the  ulcer  must  be  excised 
at  the  same  time — otherwise  subsequent  contraction  may 
occur ;  or  possibly  the  ulcer,  already  chronic,  may  persist, 
and  lead  to  a  continuance  of  the  symptoms.  In  such  a  case, 
if  excision  be  impracticable,  gastro- enterostomy  must  be 
performed. 

The  operation  of  Gastro-gastrostomy,  in  order  to  short- 
circuit  the  constriction  in  hour-glass  contraction  of  the 
stomach  due  to  chronic  ulcer,  will  be  described  later. 


128  SURGERY  OF  THE  STOMACH 

Adhesions  of  the  stomach  to  adjoining  organs  are  so 
common  in  chronic  stomach  ulceration  that  Gastrolysis,  or 
the  detaching  or  otherwise  treating  bands  and  short  ad- 
hesions to  adjoining  viscera  or  to  the  abdominal  wall,  is 
performed  in  by  far  the  greater  number  of  cases.  Such  ad- 
hesions are  frequently  the  only  remnants  of  ulcers  that  have 
healed ;  at  other  times  they  have  been  left  by  perforation  of 
the  stomach  wall  by  an  ulcer,  from  the  dire  consequences 
of  which  they  have  saved  the  patient.  In  many  cases  they 
give  rise  to  symptoms  resembling  ulcer,  though  the  adhesions 
may  be  due  to  causes  such  as  gall-stones  outside  the  stomach 
itself.  In  such  cases  the  operation  of  gastrolysis  may  be 
entirely  curative. 

We  propose  to  describe  the  operation  under  the  chapter 
dealing  with  Adhesions,  but  give  one  case  here  as  an  example 
of  the  benefits  to  be  derived  from  the  operations  of  gastroly- 
sis alone. 

Gastrolysis  for  Adhesions  caused  by  Chronic  Gastric 

Ulcer. 

Miss  M.  B.,  aged  forty-two.  Seen  by  Mayo  Robson  and  Dr. 
Holmes,  of  Garstang. 

History. — Twenty-two  years  ago  symptoms  of  ulcer  of  stomach. 
Since  then  has  suffered  from  vomiting  attacks  every  week  or  two, 
and  from  pain  after  food.  During  the  last  three  years  symptoms 
more  marked.  Under  medical  treatment,  with  rest  in  bed,  no 
improvement.  Vomited  matter  large  in  quantity  and  fermenting, 
sometimes  containing  blood.  Loss  of  weight  to  the  extent  of 
3  stones.  Great  tenderness  over  stomach,  especially  to  the  left. 
Stomach  dilated,  reaching  below  umbilicus  and  well  over  to  the 
right. 

Operation.  On  anterior  surface  of  stomach  scar  of  an  old 
ulcer.  Lesser  curvature  closely  adherent  to  the  liver.  Pyloric 
extremity  and  first  part  of  duodenum  attached  to  the  gall-bladder 
and  cystic  duct. 

January  2,  1900. — Operation.  Adhesions  separated  and  omen- 
tum interposed  between  pylorus  and  gall-bladder. 

March  7,  1900. — Perfect  recovery.  Can  eat  anything  without 
discomfort,  and  is  rapidly  putting  on  flesh. 

Has  gained  20  pounds  since  her  operation  in  January. 

Some  months  later  had  gained  2  stones  10  pounds. 


GASTRIC  ULCER  AND  ITS  COMPLICATIONS  129 

Pylorodiosis,  by  which  name  is  understood  the  operation  of 
stretching  the  pyloric  sphincter,  either  by  means  of  the 
fingers  invaginating  the  stomach  wall,  when  it  is  known  as 
'  Hahn's  operation,'  or  by  digital  or  instrumental  stretching 
after  having  made  an  opening  into  the  stomach,  when  it  is 
known  as  '  Loreta's  operation,'  is  a  method  of  little  practical 
value  in  the  treatment  of  ulcer,  and  in  some  of  the  cases 
where  we  performed  the  operation,  though  the  immediate 
results  were  good,  relapses  occurred. 

The  operation  will  be  described  under  Pyloric  Stenosis. 


CHAPTER  IX 
THE  COMPLICATIONS  OF  GASTRIC  ULCER 

Gastrorrhagia 

The  opinion  held  by  many  practitioners  of  medicine,  '  that 
bleeding  from  the  stomach  the  result  of  ulceration  rarely 
proves  fatal,'  requires  carefully  reconsidering,  and  the  facts 
marshalling  and  looking  at  also  from  the  surgical  point  of  view. 

Just  as  in  other  internal  haemorrhages,  bleeding  from  the 
stomach  was  until  quite  recently  a  subject  that,  so  far  as 
treatment  is  concerned,  only  came  under  the  notice  of  the 
physician.  It  is  only  since  the  advances  in  surgery  have 
demonstrated  the  feasibility  and  safety  of  exploring  the 
abdomen  that  the  question  of  surgical  treatment  of  haemate- 
mesis  has  been  a  subject  that  can  be  discussed  with  advan- 
tage. In  this  chapter  we  shall  confine  our  remarks  altogether 
to  the  most  common,  and  certainly  the  most  important,  cause 
of  gastrorrhagia — simple  ulcer — leaving  out  of  consideration 
for  the  present  the  vomiting  of  blood  from  cirrhosis  of  the 
liver,  cancer  of  the  stomach,  miliary  aneurism,  aneurism  of 
the  aorta  and  other  vessels,  purpura,  scurvy,  heart  disease, 
leukaemia,  typhoid  fever,  and  other  more  obscure  conditions 
only  amenable  to  medical  treatment. 

When  it  is  borne  in  mind  that  gastric  ulcer  occurs  in 
5  per  cent,  of  the  community,  and  that,  according  to  Brinton, 
"THabershon,  Mliller,  Dreschfeld,  Lebert,  and  others,  the  mor- 
tality from  all  causes  in  all  cases  of  ulcer  is  from  lo  per  cent, 
to  50  per  cent.,  it  must  be  at  once  allowed  that  the  considera- 
tion of  the  subject  is  a  matter  that  should  claim  the  attention 
of  the  profession  to  a  greater  extent  than  it  has  hitherto  done. 
Its  importance  will  be  better  grasped  if  these  figures  are 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  131 

applied  to  the  population  of  a  city  like  Leeds,  which,  for 
convenience'  sake,  we  will  take  at  500,000.  Of  this  number 
25,000  persons  may  be  supposed  to  have  or  to  have  had  ulcer 
of  the  stomach,  and  out  of  these,  taking  the  mean  estimate 
of  mortality  as  25  per  cent, — though  this  is  under  the  mean 
as  given  by  the  authorities  named — 6,250,  or  12,500  per 
1,000,000  of  the  population,  may  be  expected  to  die  from 
gastric  ulcer  or  some  of  its  complications.  When  it  is  fully 
grasped  that  many  of  the  complications  can  only  be  dealt  with 
successfully  by  surgical  means,  and  that  even  in  the  mildest 
cases  of  gastric  ulcer  some  of  the  most  serious  complications, 
such  as  perforation  and  haemorrhage,  may  suddenly  super- 
vene, we  think  that  all  will  agree  with  the  opinion  that 
physicians  and  surgeons  should,  in  the  treatment  of  these 
serious  cases,  be  in  a  closer  touch  and  have  a  more  perfect 
understanding,  so  that  valuable  time  may  be  not  lost  when 
surgical  interference  is  required.  At  present  we  have  no 
hesitation  in  expressing  a  conviction  that  the  treatment 
of  gastric  ulcer,  especially  among  the  working  classes,  is 
altogether  too  careless  and  unscientific,  and  that  the  out- 
patient treatment  of  such  cases,  whether  in  hospital  or 
private  practice,  is  absolutely  wrong  and  attended  with 
danger,  either  of  sudden  catastrophe  from  rupture  or  bleeding, 
or  of  the  transformation  of  an  acute  into  a  chronic  disease, 
which  can  then  only  in  the  greater  number  of  cases  be  set 
right  by  a  surgical  operation.  As  soon  as  gastric  ulcer  is 
suspected,  the  patient  should  be  told  the  serious  nature  of 
the  disease,  and  the  uncertainty  of  cure  without  rest  in  bed 
and  long-continued  care  in  diet  under  proper  medical  super- 
vision. If,  then,  from  business  or  other  reasons  the  advice 
of  the  medical  attendant  is  ignored,  the  blame  rests  on  the 
patient,  and  not,  as  at  present  is  so  often  the  case,  on  the 
slipshod  method  of  aiming  at  relief  and  calling  it  a  cure. 
Fortunately,  the  surgical  treatment  of  chronic  and  recurring 
gastric  ulcer  and  its  complications  is  becoming  more  and 
more  advocated,  and  with  increasing  experience  more  and 
more  perfect,  so  that  to-day  the  tale  is  very  different  from 
that  given  in  the  Hunterian  Lectures  (Mayo  Robson)  de- 
livered at  the  Royal  College  of  Surgeons  in  igoo.  One  hundred 

Q — 2 


132  SURGERY  OF  THE  STOMACH 

and  eightj'-eight  cases  of  operation  for  chronic  gastric  ulcer, 
including  thirty-four  cases  of  the  lecturer's,  but  excluding 
operations  for  perforation  and  haemorrhage,  were  then  col- 
lected. Out  of  these  cases  thirty-one  patients  died,  giving  a 
mortality  of  i6'4  per  cent. :  but  recent  experience  in  a 
large!}'  extended  number  of  cases  shows  barely  a  rate  of 
5  per  cent. ;  and  as  all  the  patients  were  either  chronic 
invalids  or  ill  unto  death,  that  means  a  saving  of  life  in 
95  per  cent,  of  the  cases,  either  by  gastro-enterostomy, 
gastroplasty,  pyloroplasty,  pylorectomy,  or  gastrolysis. 

The  complication  of  haemorrhage  from  the  stomach,  which 
according  to  different  authorities  occurs  in  a  greater  or  less 
degree  in  from  50  to  So  per  cent,  of  all  cases  of  gastric  ulcer, 
is,  it  is  said,  fatal  when  medically  treated  in  from  11  to  3  per 
cent.  (Miiller,  11  per  cent.;  Welch,  from  3  to  5  per  cent.; 
Brinton,  5  per  cent. ;  Debove,  5  per  cent. ;  Steiner,  6' ^6  per 
cent. ;  Lebert,  3  per  cent. ;  Dreschfeld,  3^  per  cent. ;  and 
Rodman,  8  per  cent.).  If  we  take  the  average,  7  per  cent, 
of  deaths  in  cases  of  gastrorrhagia  from  ulcer  will  not  be  far 
from  the  truth.  If  this  is  worked  out  in  the  500,000  popula- 
tion of  a  city  like  Leeds,  it  means  that,  of  the  25,000  persons 
who  have  or  have  had  ulcer,  12,500  suffer  from  hsematemesis, 
and  of  these  7  per  cent.,  or  875,  die.  We  are  therefore 
dealing  with  a  very  serious  and  common  accident. 

The  bleeding  may  be  arterial,  venous  or  capillary,  and, 
curiously,  capillary  haemorrhage  may  be  so  free  as  to  render 
it  difficult  to  say  that  some  large  vessel  has  not  given  way  ; 
yet  after  death  a  careful  examination  may  fail  to  discover 
any  gross  vascular  lesion.  Although  capillary  haemorrhage 
may  supervene  on  other  conditions,  such  as  congested  portal 
circulation,  enlargement  of  the  spleen,  and  engorgement  of  the 
venous  system,  when  general  treatment  will  usually  be  all- 
sufficient,  yet  there  are  two  special  conditions  in  which  the 
bleeding  may  be  so  free  as  to  raise  the  question  of  surgical 
treatment :  these  are  vicarious  haematemesis  at  the  menstrual 
period  and  post-operative  haematemesis.  The  former  condi- 
tion is  well  recognised,  and  usually  yields  to  medical  treat- 
ment. Petersen's  experience  of  surgical  treatment  in  three 
cases  terminating  fatally  after  operation  would  not  encourage 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  133 

surgical   intervention,  unless   the  circumstances   of  the  case 
were  very  exceptional. 

In  the  Hunterian  Lectures  referred  to,  attention  was  drawn 
to  post-operative  hsematemesis,  of  which  we  have  seen  several 
cases- — four  fatal.  The  cases  occurred  after  operations  for 
intestinal  obstruction,  tuberculous  peritonitis,  herniotomy, 
ovariotomy,  and  gall-bladder  operations.  Other  cases  have 
since  been  reported — one  by  Dr.  Winslow  {Lancet,  Octo- 
ber 20,  igoo,  p.  igoo)  in  a  stout  woman,  aged  sixty-five  years, 
after  operation  for  umbilical  hernia,  where  death  occurred 
from  profuse  gastrorrhagia  on  the  third  day ;  and  at  the 
post-mortem  examination,  though  the  stomach  and  intestines 
contained  a  large  quantity  of  blood,  no  vascular  lesion  could 
be  discovered;  and  another  by  Mr.  C.  W.  Mansell-Moullin 
Lancet,  October  20,  igoo,  p.  igoo)  in  a  young  man,  aged 
twenty-three  years,  who  died  from  profuse  hasmatemesis 
within  forty-eight  hours  of  a  simple  exploratory  incision  in 
the  left  iliac  fossa.  Post-operative  hsematemesis  was  then 
neither  generally  recognised  nor  well  understood,  but  since 
that  time  several  papers  have  appeared  on  the  subject  both 
at  home  and  abroad,  and,  though  now  fully  recognised,  its 
cause  remains  obscure.  Professor  von  Eiselsberg  tried  to 
explain  it  as  a  result  of  injury  to  the  omentum  from  several 
cases  observed  in  the  Konigsberg  Klinik  after  operations 
involving  ligature  of  the  omentum,  after  proctectomy  for 
cancer,  and  after  torsion  of  the  omentum.  Although  this 
explanation  may  serve  as  a  cause,  it  does  not  account  for  all 
cases,  as  proved  by  one  in  which  a  malignant  tumour  of  the 
common  bile-duct  causing  jaundice  and  distended  gall- 
bladder was  operated  on  under  cocaine  (A.  W.  M.  R.),  the 
distended  gall-bladder  being  simply  exposed  through  a  small 
incision,  stitched  to  the  parietes  and  drained,  without  in  any 
way  exposing  any  other  viscera  ;  yet  violent  hcsmatemesis 
set  in  the  day  after  operation,  and  proved  fatal  in  three  days. 
This  case  also  disproves  two  other  theories  that  have  been 
advanced — one,  that  general  anaesthesia  is  the  cause,  and 
another,  that  sepsis  affords  an  explanation,  the  latter  being  a 
theory  advanced  by  Dr.  Rodman  in  his  oration  before  the 
American  Medical  Association  in  June,  igoo.    That  sepsis  was 


134  SURGERY  OF  THE  STOMACH 

not  the  explanation  in  the  cases  in  which  the  opportunity  has 
occurred  of  observing  the  condition  after  death  is  undoubted, 
for  in  each  there  was  no  sign  of  peritonitis  or  other  septic 
trouble  ;  and,  moreover,  there  was  no  gross  evidence  of  ulcer 
or  other  injury  to  any  vessel  of  sufficient  size  to  be  visible  to 
the  naked  e3'e.  The  theory  of  sepsis  is  also  negatived  by  re- 
covery in  the  greater  number  of  cases,  and  by  there  being  no 
sign  of  distension  or  any  of  the  other  usual  concomitants  of 
septicaemia  when  it  occurs  after  abdominal  operations.  The 
only  explanation  that  seems  at  all  feasible  is  that  the  haemor- 
rhage is  dependent  on  a  reflex  nervous  influence,  and  it  is 
quite  possible  that  this  same  explanation  applies  to  vicarious 
haematemesis  at  the  menstrual  period ;  but  it  should  also  be 
remembered  that  slight  erosion  of  the  mucous  membrane  of 
the  stomach,  sufficiently  deep  to  cause  severe  gastrorrhagia, 
may  be  almost  imperceptible  to  the  naked  eye,  even  when 
searched  for  carefully  on  the  post-mortem  table.  Though 
serious,  it  is  not  necessarily  fatal,  and  I  have  known  several 
cases  yield  to  general  treatment,  such  as  high  injections  of 
hot  water  at  a  temperature  of  from  112°  to  116°  F.,  as  advo- 
cated by  Tripier,  free  purgation  by  calomel,  the  stopping  of 
all  mouth-feeding,  and  the  application  of  ice  to  the  epigas- 
trium, etc.  In  post-operative  haematemesis,  operation  can 
be  seldom  feasible  or  advisable,  and  Reichard's  experience  of 
operations  followed  by  death  in  two  cases  would  lead  one  in 
the  future,  as  in  the  past,  to  rely  on  general  rather  than  on 
surgical  treatment. 

Venous  haemorrhage,  if  from  perforation  of  one  of  the  large 
trunks,  such  as  the  coronary,  splenic,  or  portal,  may  cause 
rapid  death ;  but,  owing  to  the  diminished  pressure  in  the 
veins  and  the  more  languid  circulation,  a  rapidly  fatal  result 
is  less  likely  than  in  arterial  bleeding,  and  should  the  haemor- 
rhage persist  or  recur,  such  cases  would  be  likely  to  benefit 
by  surgical  treatment. 

Arterial  bleeding  is  mostly  responsible  for  the  serious  and 
fatal  haematemesis  due  to  gastric  ulcer.  The  bleeding  may 
be  from  the  small  arterioles  which  radiate  betw^een  the  peptic 
glands,  from  the  trunks  along  the  curvatures  (the  coronary 
being  the  most  frequently  affected),  or  from  extrinsic  arteries. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  135 

the  splenic  alone  being  responsible,  according  to  Brinton, 
for  55  per  cent,  of  the  deaths  in  fatal  haematemesis. 

The  following  list  of  54  fatal  cases  of  haematemesis  is 
taken  from  M.  Savariaud's  thesis:  Ulcerations  of  the  splenic 
artery,  17  cases  ;  ulcerations  of  the  coronary  artery,  6  cases  ; 
ulcerations  of  the  pancreatico-duodenal,  7  cases ;  ulcera- 
tions of  the  gastric  arterioles,  10  cases ;  branches  of  the 
coronary  vein,  2  cases ;  other  veins,  2  cases ;  vessel  not 
determined,   2   cases  ;    no  vascular  orifice  visible,  4  cases ; 


Fig.    33. — Stomach  showing  large  Varicose  Veins. 

Perforation  occurred  at  two  places  and  led  to  fatal  hsemorrhage. 
(No.  2,402,  Royal  College  of  Surgeons'  Museum.) 


vessel  not  mentioned,  4  cases.  The  pancreatico-duodenal 
and  right  gastro-epiploic  are  the  arteries  chiefly  affected  in 
pyloric  and  duodenal  ulcers.  The  peculiarly  fatal  nature  of 
hccmorrhages  from  medium-sized  arteries  depends  on  the 
fact  that  an  ulcer  makes  a  lateral  opening  into  the  vessel 
which  prevents  natural  hsemostasis  by  retraction  and  con- 
traction of  the  artery.  The  whole  force  of  the  heart  is  then 
exerted  on  the  clot,  which  tends  to  form  during  the  syncope 
that  usually  occurs  when  a  large  quantity  of  blood  is  suddenly 
poured  out. 

The  interval  between  the  first  onset  of  bleeding  and  death 
is  of  great  importance  surgically,  and  is  well  shown  in  the 


136 


SURGERY  OF  THE  STOMACH 


table  from  M.  Savariaud's  thesis,  which  is  therefore  worthy 
of  note : 


Survived 

Vessel. 

No.  of 

Sudden 

Rapid 

considerable 

Cases. 

Death. 

Death. 

Time. 

Heart 

4 

I 

I 

2  (3  days) 

Aorta 

2 

— 

I 

I  (lo  days) 

Hepatic 

2 

— 

I 

I  (lo  days) 

Splenic 

I? 

3 

7 

7  (2  to  8  days) 

Coronary 

6 

I 

3 

2 

Pancreatico-  duodenal 

6 

I 

3 

2  (8  to  15  days) 

Arterioles 

lO 

I 

I 

8  (4  to  15  days) 

Small  veins     ... 

4 

I 

I 

2  (7  to  1 1  days) 

Invisible  veins 

3 

I 

2  (21  days) 

It  shows  that  in  the  present  state  of  our  knowledge  it  is 
impossible  to  diagnose  the  size  of  the  vessel  perforated,  either 
from  the  amount  of  blood  lost  or  the  length  of  survival. 

A  probable  diagnosis  of  the  site  of  the  bleeding  may,  how- 
ever, often  be  arrived  at  in  haematemesis  from  ulcer  by  a 
careful  study  of  the  previous  history,  especially  with  regard 
to  the  site  of  pain,  the  time  of  onset  after  food,  and  the 
influence  of  posture,  as  well  as  by  the  direction  in  which  the 
pain  radiates.  The  situation  of  the  tender  spot,  the  presence 
or  absence  of  tumour,  and  of  dilatation  or  contraction  of  the 
stomach,  also  afford  assistance. 

As  will  be  seen  later,  the  diagnosis  of  the  site  of  the  ulcer, 
and  therefore  presumably  of  the  bleeding,  is  of  great  im- 
portance from  a  surgical  point  of  view,  and  will  influence 
both  the  advice  given  as  to  treatment  and  the  method  of 
procedure  when  the  abdomen  is  opened. 


Treatment. 

From  the  fact  that  medical  and  general  treatment  is 
successful  in  arresting  haematemesis  in  93  per  cent,  of  cases, 
and  that  it  is  difficult  in  the  present  state  of  our  knowledge 
to  say  at  first  that  the  bleeding  is  not  occurring  from 
capillaries  or  small  arterioles,  it  necessarily  follows  that 
medical  treatment  should  always  have  a  fair  trial  in  every 
case  of  acute  haematemesis.     The  very  fact  of  medical  treat- 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  i2>7 

merit  being  so  often  successful  in  cases  of  apparently  alarming 
haematemesis  goes  to  show  that  capillary  oozing  or  bleeding 
from  arterioles  is  much  more  common  and  accounts  for 
many  more  cases  of  gastric  haemorrhage  than  has  hitherto 
been  supposed;  but  while  thoroughly  believing  this,  we  must 
also  not  close  our  eyes  to  the  experience  we  have  in  general 
surgery  of  bleeding  from  medium-sized  arteries,  such  as  the 
radial  or  ulnar,  which  we  know  would  rapidly  bleed  a  patient 
to  death  if  the  vessel  were  perforated  on  one  side  and 
surrounded  by  warm  compresses,  a  condition  that  practi- 
cally applies  in  all  cases  of  hcematemesis  where  the  larger 
vessels  are  eroded. 

If,  therefore,  medical  treatment  and  rest  properly  carried 
out  are  not  successful  in  arresting  the  bleeding  in  a  few 
hours,  or  if  after  being  arrested  the  bleeding  recurs,  we 
should  be  driven  to  the  conclusion  that  a  large  vessel  is  per- 
forated ;  and  if  a  surgeon  has  not  been  previously  asked  to 
see  the  case,  we  would  say  emphatically  that  a  surgical  con- 
sultation ought  to  be  held  with  a  view  to  considering  the 
question  of  operation  and  immediate  arrest  of  the  bleeding 
by  direct  treatment  if  the  patient  is  in  a  fit  condition  to  bear 
it,  just  as  would  be  the  case  if  an  ovarian  artery  were  bleed- 
ing in  a  case  of  ruptured  extra-uterine  gestation,  or  a  brachial 
or  radial  after  an  accident. 

The  views  here  enunciated  are  perhaps  more  pronounced 
and  more  emphatic  than  those  expressed  in  the  Hunterian 
Lectures  of  1900,  this  being  the  result  of  a  much  extended 
experience  in  the  surgery  of  the  stomach,  a  much  greater 
success  on  all  hands  in  the  surgical  treatment  of  stomach 
diseases,  and  a  careful  study  of  more  recent  statistics. 

An  analysis  of  the  table  of  M.  Savariaud  of  54  cases  show- 
ing the  prolongation  of  life  in  various  fatal  cases  of  haema- 
temesis, demonstrates  that  in  10  out  of  54 — that  is,  in 
18-5  per  cent. — death  occurs  so  rapidly  that  there  is  barely 
time  to  consider  the  question  of  surgical  treatment,  and  that 
in  17  out  of  the  54,  which  equals  31*4  per  cent.,  death  occurs 
within  from  twenty-four  to  thirty-six  hours  after  the  first 
appearance  of  haemorrhage.  Now,  although  at  present  these 
cases  are  often  allowed  to  die  without  operation,  yet  if  the 


138  SURGERY  OF  THE  STOMACH 

bleeding  were  from  a  radial  or  tibial,  or  any  accessible 
artery,  they  would  all  be  saved  by  the  simple  operation  of 
direct  ligature  of  the  bleeding  vessel,  an  operation  which 
would  also  cure  the  bleeding  stomach  artery  could  it  be 
readily  found.  The  difference  between  the  two  is,  however, 
not  only  one  of  accessibility,  but  also  one  of  diagnosis ;  for 
if  we  are  able  to  diagnose  capillary  haemorrhage,  the  case 
will  be  generally  one  for  medical  treatment  alone,  but  if  the 
time  arrives  when  we  can  diagnose  with  great  probability 
arterial  hasmorrhage  from  a  large  vessel,  the  case  will,  we 
believe,  be  considered  one  for  the  adoption  of  surgical 
measures.  Our  efforts,  both  as  physicians  and  surgeons, 
must  therefore  be  directed  towards  making  a  diagnosis  of 
the  size  of  the  damaged  vessel,  for  if  it  can  be  asserted  that 
in  all  probability  a  large  artery  has  given  way,  an  operation 
could  be  undertaken  in  an  early  stage  of  the  case,  before 
exhaustion  and  profound  anaemia  have  supervened,  with  great 
probability  of  success. 

Where  there  have  been  distinct  signs  of  gastric  ulcer 
preceding  the  haemorrhage,  and  where  a  sudden  hsematemesis 
has  occurred,  with  great  loss  of  blood,  accompanied  by  an 
attack  of  syncope,  a  large  vessel  will  usually  be  found  to  be 
the  source  of  the  bleeding.  In  all  such  cases  not  speedily 
yielding  to  medical  and  general  means,  surgical  treatment 
will  probably  in  the  future  be  carefully  considered,  and 
in  some  it  will  be  followed  out ;  for  there  can  be  no  absolute 
rule  formulated  that  will  apply  to  every  case,  and  each  must 
be  considered  on  its  merits.  The  present  condition  of  the 
patient,  the  previous  history,  the  surroundings,  the  possibility 
of  skilled  surgery  and  of  good  nursing,  and  other  like  circum- 
stances, will  all  help  in  the  decision. 

Although  both  surgical  and  medical  treatment  in  cases  of 
fulminating  haemorrhage  have  so  far  yielded  disappointing 
results,  in  the  remaining  50  per  cent,  of  fatal  haemorrhages, 
where  repeated  bleedings  occur,  and  the  interval  between  the 
first  seizure  and  death  varies  from  a  few  days  to  two  or  three 
weeks,  medical  treatment  will  have  been  fully  tried  and 
failed,  and  there  can  be  no  question  as  to  the  advisability 
of  surgical  procedures  being  adopted. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  139 

At  present,  with  the  exception  of  Dieulafoy,  who  advocates 
operation  during  the  first  bleeding  if  as  much  as  \  Htre  of 
blood  is  lost,  all  other  surgeons  who  have  written  on  the 
subject  agree  that  general  means  ought  to  be  relied  on  during 
and  after  a  first  attack,  as  in  from  93  to  95  per  cent,  of  cases 
such  treatment  succeeds,  and  until  our  means  of  diagnosis  as 
to  the  size  of  the  vessel  injured  is  rendered  more  reliable  we 
must  assent  to  this  rule ;  but  after  a  second  bleeding  we  have 
no  hesitation  in  advising  operation,  even  during  the  course  of 
the  hsemorrhage  if  the  patient  can  bear  it,  or  as  soon  after  as 
his  condition  will  permit  the  operation  to  be  done :  for 
experience  tells  us  that  further  haemorrhages  are  almost 
certain  to  occur  unless  preventive  measures  be  adopted. 
One  of  us  (A.  W.  M.  R.)  saw  a  case  of  this  kind  which 
created  a  great  impression.  A  single  woman,  close  on  thirty, 
was  seen,  with  a  view  to  operation,  after  a  second  attack  of 
hsematemesis,  which  had,  however,  then  ceased,  and  as  the 
patient,  though  ansemic,  was  apparently  much  easier,  and 
expressed  herself  as  feeling  well,  operation  was  deferred ; 
but  a  third  attack,  which  occurred  a  few  days  later,  proved 
fatal. 

In  another  case,  operated  on  during  the  third  attack,  the 
bleeding  vessels  were  found  and  ligatured,  and  the  patient 
was  saved. 

Doubtless  the  desirability  of  stopping  bleeding  from  an 
ulcer  of  the  stomach  by  surgical  means  must  have  occurred 
to  many  minds  before  being  put  into  execution.  To  Mikulicz, 
however,  belongs  the  claim  of  having  been  the  first  to  operate 
for  haemorrhage  from  a  gastric  ulcer,  on  February  13,  1887. 
Roux  of  Lausanne  was  the  first  to  perform  a  successful 
operation  in  a  case  of  hsemorrhage  from  the  coronary  artery, 
in  which  he  excised  the  ulcer  and  ligatured  the  artery  at  both 
ends.  In  the  Hunterian  Lectures  a  table  of  all  the  cases  of 
operations  for  h^matemesis  was  given  ;  it  included  operations 
for  post-operative  and  vicarious  hsemorrhage,  cases  not  asso- 
ciated with  ulceration,  and  all  ending  fatally.  Excluding 
these  and  correcting  Hartmann's  series,  it  would  give  26 
cases  of  acute  hsematemesis,  with  14  deaths,  and  ig  cases 
of    chronic    hsematemesis,    with    2    deaths ;     otherwise    a 


140  SURGERY  OF  THE  STOMACH 

mortality  of  53*8  per  cent,  in  acute,  and  of  10*5  per  cent, 
in  chronic,  hsematemesis  treated  surgically.  A  more  recent 
table  has  been  drawn  up  by  Dr.  Rodman  {Philadelphia  Medical 
Journal,  June  g,  1900),  in  which  he  has  collected  32  operations 
for  acute  gastrorrhagia,  with  13  deaths,  or  a  40*6  per  cent, 
mortalit}',  and  31  operations  for  frequently-recurring,  or  so- 
called  chronic,  haemorrhages,  with  6  deaths,  or  a  mortality 
of  ig*3  per  cent. ;  and  even  since  that  list  was  drawn  up 
other  operations  have  been  performed.  This  mortality  is 
very  high,  but  it  must  be  remembered  that  in  every  case 
medical  treatment  had  been  first  tried,  and  in  many  of  the 
cases  probably  over  too  long  a  period  before  operation  was 
performed ;  for  instance,  in  one  of  the  cases  given,  in  which 
one  of  us  (A.  W.  M.  R.)  operated  successfully  during  the 
third  seizure,  the  blood  seen  at  the  operation  was  so  diluted 
and  thin  as  to  be  more  like  water  tinged  with  blood  than 
blood  itself,  yet  the  bleeding  was  still  going  on.  Moreover, 
it  is  to  be  remembered  that  gastric  surgery  is  advancing  in 
safety  and  efficiency  by  leaps  and  bounds,  and  will,  we  feel 
sure,  be  one  of  the  most  satisfactory  branches  of  the  surgeon's 
work. 

Technique  of  Operation  for  Gastrorrhagia  (Exploratory  Gastro- 
tomy). — On  account  of  the  fear  of  exciting  fresh  haemorrhage, 
it  is  undesirable  to  wash  out  the  stomach  before  operating  on 
a  bleeding  ulcer ;  and  as  the  patient  is  usually  anaemic,  and 
will  therefore  bear  shock  badly,  it  is  desirable  to  have  him 
enveloped  in  cotton-wool  or  otherwise  kept  w^arm  on  a 
heated  table,  and  to  give  him  a  subcutaneous  injection  of 
strychnine  before  operation.  If  it  be  unnecessary  to  infuse 
saline  fluid  before  the  operation,  an  assistant  should  be 
ready  to  perform  that  duty  while  the  abdominal  operation 
is  being  proceeded  with,  should  it  be  called  for.  After  the 
abdomen  is  opened,  the  stomach  may  be  emptied  by  pressing 
the  contents  into  the  duodenum,  as  suggested  by  M.  Terrier. 
This  saves  much  time,  and  rapidity  is  of  great  importance. 
The  surface  of  the  stomach  should  then  be  carefully 
examined,  as  very  frequently  a  puckering  of  the  surface 
or  thickening  of  the  coats  will  be  noticed  at  the  site  of 
the  ulcer,  or  a  difference  in  colour  may  sometimes  indicate 


THE  COMPLICATIONS  OF  GASTRIC  ULCER 


141 


its  site.  Should  the  operator  be  fortunately  able  to  find 
these  indications,  much  time  may  be  saved ;  but  if  no 
indications  of  this  sort  be  obtainable,  the  stomach  must 
be  drawn  well  forward  and  opened,  either  by  a  vertical 
incision,  which  gives  less  haemorrhage,  or  by  an  incision 
in  the  long  axis  of  the  stomach,  which  affords  a  much  better 
view  of  the  interior.  In  order  to  avoid  soiling  the  peri- 
toneum,   thin,    flat    sponges    should    be    placed   within    the 


Fig.  34. — Method  of  Exposure  of  Ulcer. 


abdomen,  and  it  is  well  to  have  a  perforated  sterilized  gauze 
pad  covering  the  stomach,  the  opening  to  correspond  with 
the  opening  in  the  stomach.  The  edges  of  the  stomach 
should  then  be  held  open  by  forceps,  one  above  and  below, 
and  one  at  each  end. 

The  interior  of  the  stomach  must  now  be  systematically 
examined — first  the  anterior  and  posterior  surfaces,  then 
the  upper  and  lower  curvatures,  and  lastly  the  pyloric  and 


142 


SURGERY  OF  THE  STOMACH 


cardiac  orifices,  all  of  which  can  be  done  by  the  naked  eye, 
or  by  the  aid  of  an  electric  cystoscope  or  a  reflected  light. 
If  the  posterior  wall  of  the  stomach  cannot  be  sufficiently 
examined,  a  slit  may  be  made  in  the  omentum,  and  two 
fingers,  or  even  the  whole  hand,  pushed  through  it,  and 
emplo3'ed  to  invaginate  the  posterior  wall.  If  no  ulcer 
can  be  found  on  the  wall  of  the  stomach,  the  duodenum 
should  be  explored,  not  only  by  the  finger,  but  by  invagina- 


FiG.  35. — Ligature  of  Bleeding-Point. 


tion.  If  no  ulcer  be  found  anywhere,  and  the  bleeding 
proves  to  be  capillary  or  from  small  undiscoverable  ulcers, 
gastro-enterostomy  should  be  performed ;  but  if  an  ulcer  be 
discovered,  and  it  be  possible  to  excise  it,  that  operation 
should  be  done,  as  it  undoubtedly  offers  the  likeliest  method 
of  cure.  After  excision  of  the  ulcer  and  ligature  of  the 
bleeding  vessels,  the  edges  of  the  wound  are  brought 
together  by  sutures,  of  which  one  or   two  layers  may  be 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  143 

employed.  Should  the  excision  involve  the  peritoneal  coat, 
it  is  desirable  to  apply  Lembert's  sutures,  and  if  it  be  on 
the  posterior  wall  the  operation  may  present  some,  though 
not  insuperable,  difficulty.  Should  the  ulcer  be  discovered 
in  some  region  where  excision  is  impracticable — for  instance, 
near  the  cardiac  end — the  method  adopted  by  Mikulicz,  in 
his  first  operation,  in  1887,  of  applying  the  cautery,  may  be 
employed.  This  seems  to  have  answered  well  in  several 
cases,  and  where  death  occurred  afterwards  it  was  not 
from  a  recurrence  of  the  bleeding.  In  a  case  of  this  kind 
gastro-enterostomy  is  also  advisable,  by  way  of  setting  the 
stomach  at  rest.  If  any  superficial  bleeding-points  be  dis- 
covered, they  may  be  caught  up  by  forceps  and  ligatured ; 
but  this  is  more  easily  said  than  done,  as  the  mucous 
membrane  is  very  friable,  and  a  ligature,  if  drawn  at  all 
tightly,  tends  to  cut  its  way  through.  Moreover,  forceps 
easily  tear  the  mucous  membrane,  and  may  produce  a  larger 
bleeding  area.  The  method  of  ligature  en  masse  may  be 
employed  if  the  ulcer  is  small ;  it  has  proved  serviceable 
in  several  cases — for  instance,  in  Case  4,  which  will  be 
described  presently — and  it  is  easy  of  application  when  the 
ulcer  can  be  reached. 

The  method  has  been  tested  by  experiments  on  animals  by 
Dr.  Eisendrath  (Annals  of  Surgery),  and  has  been  shown  to 
endanger  perforation  if  the  serous  coat  be  taken  up,  except 
when  supported  by  external  sutures.  Ligature  of  the  main 
arteries  of  the  stomach  was  suggested  theoretically  by 
Savariaud  when  no  bleeding  ulcer  could  be  discovered ;  it 
does  not,  however,  commend  itself  as  being  safe  or  likely  to 
be  efficient.  Should  the  bleeding  be  from  an  ulcer  at  the 
pylorus,  the  operation  of  pyloroplasty  may  be  performed,  the 
ulcer  being  excised,  and  the  edges  of  the  gap  left  by  the 
excised  ulcer,  as  well  as  the  edges  of  the  incision,  being 
united,  so  that  the  line  of  sutures  shall  be  transverse  to 
the  axis  of  the  pylorus.  We  should  not,  however,  advise 
pyloroplasty  when  there  is  active  ulceration  of  the  pylorus, 
unless  the  ulcer  can  be  completely  excised ;  for  in  three 
cases  of  this  kind  there  have  been  subsequent  disappoint- 
ments, owing  to  contraction  in  healing.     In  one  case  the 


144  SURGERY  OF  THE  STOMACH 

patient  made  a  good  recovery  from  the  operation,  but  sub- 
sequently suffered  from  stenosis,  for  which  a  further 
operation  had  to  be  done.  In  a  second  case  recovery  took 
place,  and  the  patient  regained  his  lost  v^^eight ;  but  sub- 
sequently a  tumour  of  the  pylorus  developed,  which  was 
thought  to  be  cancer,  and  for  which  pylorectomy  had  to 
be  performed.  In  the  third  case  perforation  subsequently 
occurred.  We  think,  therefore,  that  in  cases  of  ulcer  of  the 
pylorus,  where  a  clean  excision  of  the  pylorus  cannot  be 
done,  it  would  be  better  to  perform  gastro-enterostomy  or 
pylorectomy,  whichever  at  the  time  may  appear  to  be  the 
easier. 

Wherever  the  pylorus  is  adherent,  as  it  is  in  so  many  cases 
of  ulcer,  we  should  certainly  prefer  gastro-enterostomy  ;  but 
if  the  pylorus  be  extensively  ulcerated  and  free  from  ad- 
hesions, pylorectomy  can  be  almost  as  quickly  performed  as 
gastro-enterostomy,  seeing  that  the  pylorus  is  already  in  the 
hand. 

Although  the  operative  treatment  of  parenchymatous  or 
capillary  haemorrhage  by  any  surgical  method  would  seem 
to  be  of  doubtful  value  [for,  according  to  a  report  by  Peter- 
sen (Medical  Press,  i8gg)  from  Czerny's  clinic,  of  three  cases 
operated  upon  for  severe  parenchymatous  haemorrhage  from 
vicarious  menstruation,  operation  entirely  failed  to  relieve, 
and  of  other  two  cases  of  post-operative  parenchymatous 
haemorrhage  by  Reichard  {Medical  Press,  January  3,  igoo) 
both  died],  yet  if  such  cases,  owing  to  persistence,  seem 
to  call  for  operation,  then  gastro-enterostomy,  by  securing 
complete  physiological  rest,  would  seem  to  offer  the  best 
chance  of  success. 

In  performing  gastro-enterostomy  our  recent  experience 
has  led  us  to  prefer  the  posterior  operation,  which  may  be 
modified  by  using  Mayo  Robson's  decalcified  bone  bobbin 
as  a  hollow  splint  over  which  to  apply  the  double  continuous 
suture,  uniting  the  mucous  and  serous  margins  of  the  open- 
ings between  the  viscera,  thus  securing  an  immediately 
patent  channel  between  the  stomach  and  jejunum,  and  a 
temporary  protection  to  the  line  of  union.  We  may  say  that 
our  last  thirty  or  more  posterior  gastro-enterostomies  have 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  145 

recovered  without  regurgitant  vomiting   or  other  untoward 
symptoms. 

The  conclusions  we  would  urge  concerning  the  treatment 
of  bleeding  gastric  ulcer  are  that — 

1.  In  recurring,  or  so-called  chronic,  h^ematemesis  from 
gastric  ulcer,  surgical  treatment  is  decidedly  called  for. 

2.  In  acute  hasmatemesis,  further  accuracy  in  diagnosis  as 
to  the  size  of  the  bleeding  vessels  is  urgently  needed,  and 
the  co-operation  of  the  physician  and  surgeon  is  advisable  in 
all  cases  of  hgematemesis,  so  that,  if  relief  be  not  obtained 
by  medical  and  general  treatment,  surgical  means  may  be 
adopted  if  the  bleeding  is  believed  to  occur  from  a  large 
vessel ;  but  seeing  that  capillary  haemorrhage  is  capable  of 
relief  by  medical  means  alone,  medical  should  always  pre- 
cede surgical  treatment  in  such  cases. 

The  following  are  brief  descriptions  of  all  the  cases  of 
acute  hffimatemesis  on  which  one  of  us  (Mayo  Robson)  has 
operated  : 

Case  i. — Acute  hsematemesis  from  ulcer  of  duodenum  close  to 
pylorus,  eroding  gastro-duodenal  artery.  Anterior  gastro-enteros- 
tomy  with  Murphy's  button. 

The  patient  was  a  man,  aged  thirty-six,  who  after  a  year's  history 
of  ulcer  of  the  stomach,  with  great  loss  of  flesh  and  strength,  was 
suddenly  seized  with  profuse  hsematemesis,  which  was  followed 
in  twenty-four  hours  by  a  second  seizure.  When  seen  he  was 
extremely  weak  and  very  thin  and  anaemic,  and  looked  as  if  he 
must  die  if  further  haemorrhage  occurred.  His  pulse  at  the  time 
of  operation  was  150. 

The  history  clearly  pointed  to  the  pylorus  or  duodenum  as 
being  the  seat  of  the  bleeding,  but  the  patient  was  too  ill  to  bear 
pylorectomy,  and  an  anterior  gastro-enterostomy  was  performed 
by  means  of  a  Murphy  button,  the  whole  operation  only  occupy- 
ing fifteen  minutes.  He  bore  the  shock  well,  and  for  five  days 
made  good  progress.  On  the  sixth  day  he  was  suddenly  seized 
with  severe  abdominal  pain,  and  from  that  time  he  lost  strength. 
Vomiting  set  in  on  the  eighth  day,  and  he  died  on  the  tenth.  No 
further  bleeding  occurred,  and  at  the  necropsy  a  duodenal  ulcer 
opening  into  the  gastro-duodenal  artery  was  found.  The  cause 
of  death  was  peritonitis,  the  result  of  a  leakage  when  the  button 
began  to  separate. 

So  far  as  the  haemorrhage  was  concerned,  the  gastro-enteros- 

10 


146  SURGERY  OF  THE  STOMACH 

tomy  had  been  completely  successful,  and  the  vessel,  though 
perforated  at  one  side,  was  occupied  by  a  firm  clot. 

Case  2. — Pyloric  ulcer  ;  haematemesis.     Gastro-enterostomy. 

Mr.  C,  aged  forty-four,  was  sent  by  Dr.  Peter  MacGregor,  of 
Huddersfield,  on  January  2,  igoo,  with  the  history  that  he  had 
had  pain  after  food,  together  with  other  symptoms  of  gastric  ulcer, 
for  four  years,  though  his  first  attack  of  vomiting  blood  occurred 
in  May  of  the  previous  year.  The  bleeding  was  rather  profuse, 
but  under  medical  treatment  and  rest  he  recovered  and  was  able 
to  resume  his  occupation.  A  week  before  he  was  sent,  there  had 
been  a  recurrence  of  the  haemorrhage,  which  was  repeated  three 
days  later. 

On  his  arrival  at  the  surgical  home  he  was  in  a  state  of  collapse 
with  a  barely  perceptible  pulse.  There  was  well-marked  dilata- 
tion of  the  stomach,  with  tenderness  over  the  pylorus.  The 
history  of  the  pain  occurring  one  and  a  half  hours  after  food, 
together  with  the  site  of  the  tenderness  and  the  presence  of  a 
large  amount  of  blood  in  the  motions,  left  no  doubt  but  that  the 
ulcer  was  at  or  near  the  pylorus.  As  the  bleeding  had  recurred 
twice  in  the  week,  and  was  probably  persisting  and  passing  into 
the  bowel,  operation  was  decided  on.  This  was  done  on  January  4. 
As  the  patient  was  in  such  a  feeble  condition,  every  precaution 
was  taken  to  guard  against  shock,  and  it  was  decided  only  to 
perform  gastro-enterostomy,  as  it  was  quite  clear  that  he  would 
not  stand  any  prolonged  search  for  the  bleeding-point.  A  posterior 
gastro-enterostomy  was  therefore  done,  a  decalcified  bone  bobbin 
being  used  to  make  the  anastomosis.  His  temperature  and  pulse 
were  never  above  normal,  and  he  made  an  uninterrupted  recovery. 
He  was  fed  by  nutrient  enemata  for  the  first  few  days,  only  taking 
sips  of  water  by  the  mouth  ;  but  at  the  end  of  that  time  he  was 
allowed  to  take  milk  and  soda-water,  and  then  gradually  to  have 
stronger  food.  He  was  up  at  the  end  of  the  third  week,  and 
returned  home  within  the  month. 

A  year  later  he  was  in  perfect  health,  and  had  had  no  recur- 
rence of  his  stomach  symptoms  nor  any  further  bleeding. 

Case  3. — On  July  6  one  of  us  was  asked  by  Dr.  Humphery, 
of  Armley,  to  see  a  patient,  Mrs.  H.,  aged  thirty-three,  who  had 
been  seized  with  violent  haematemesis  a  week  previously,  the 
attack  having  recurred  four  days  later,  and  again  on  the  day 
we  saw  her.  The  patient  had  been  anaemic  before  operation, 
and  had  had  some  slight  indigestion,  but  otherwise  did  not  con- 
sider herself  ill,  and  she  had  been  married  only  three  months. 
On  arrival  we  found  her  quite  blanched  and  with  a  very  rapid, 
feeble  pulse  ;  but  as  the  bleeding  had  resisted  ordinary  remedies, 
and    as   she   was   clearly   going    to    die   if    unrelieved,    though 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  147 

it  seemed  a  rather  desperate  procedure,  we  decided  to  give 
her  the  chance  of  rehef  by  operation.  She  was  removed  by 
ambulance  to  a  surgical  home,  and,  as  during  the  journey  the 
bleeding  began  again,  an  operation  was  done  without  delay.  A 
pint  of  saline  fluid  containing  i  ounce  of  brandy  was  given  into 
the  rectum,  and  10  minims  of  liq.  strychnise  were  administered 
just  before  the  operation,  the  patient  being  completely  enveloped 
in  cotton-wool.  On  opening  the  abdomen  there  were  no  indica- 
tions on  the  surface  of  the  stomach  as  to  the  situation  of  the 
bleeding  ulcer.  An  incision  was  therefore  made  in  the  axis  of 
the  stomach,  which  enabled  us  to  explore  the  interior.  No  less 
than  seven  bleeding-points  were  counted.  As  two  of  them  were 
bleeding  freely,  they  were  taken  up  by  artery  forceps  and  the 
mucous  membrane  was  ligatured  en  masse ;  the  other  bleeding- 
points  stopped  on  exposure  to  air.  We  then  rapidly  closed  the 
wound  in  the  stomach  and  performed  posterior  gastro-enteros- 
tomy,  using  one  of  the  bone  bobbins  as  a  splint  over  which  to 
make  the  anastomosis.  We  had  a  little  anxiety  on  account  of 
shock  for  the  first  twenty-four  hours,  but  by  administering  saline 
fluid  by  the  bowel  and  injecting  it  freely  into  the  subcutaneous 
tissue,  together  with  the  administration  of  several  injections  of 
liq.  strychniae,  the  difficulties  were  tided  over,  and  the  patient's 
further  progress  towards  recovery  was  uninterrupted.  She  was 
able  to  take  solid  food  in  the  second  week,  and  when  she  left  at 
the  end  of  the  month  she  could  eat  any  ordinary  food  without 
discomfort.  Six  months  later  she  had  had  no  recurrence  of 
symptoms  and  was  well  in  every  respect. 

Case  4. — Mr.  F.,  a  farmer,  residing  in  Essex,  was  sent  by 
Dr.  A.  J.  T.  White,  on  March  26,  who  kindly  furnished  the 
following  history : 

'  I  first  saw  him  five  years  ago  ;  he  had  then  occasional  pain  in 
the  epigastrium,  with  much  flatulence,  and  at  times  vomiting. 
This  kept  on  at  intervals  more  or  less  for  three  years.  Eighteen 
months  Dr.  G.  saw  him  with  me.  At  that  time,  instead  of  his 
former  weight  of  16  stones,  he  only  turned  the  scale  at  12  stones. 
He  then  improved  gradually  for  about  three  months,  and  gained 
about  a  stone  in  weight.  Six  months  later,  or  about  a  year  ago, 
he,  while  out  driving,  had  some  abdominal  pain,  and  vomited 
considerable  quantities  of  blood.  He  continued  being  sick  and 
suffering  pain  for  some  time,  with  slight  haematemesis  and 
melaena,  but  again  improved.  About  three  or  four  months  ago 
he  got  worse,  and  has  been  vomiting  and  suffering  considerable 
pain  on  and  off"  ever  since.  I  have  very  little  doubt  but  that  his 
original  trouble  was  gastric  ulcer,  but  my  fear  now  is  lest 
malignant  ulceration  should    have  supervened,  and   some   time 

10 — 2 


148  SURGERY  OF  THE  STOMACH 

ago  I  asked  him  to  see  you.  He  could  not  go  then,  as  he  had 
various  business  matters  to  set  right,  but  now  is  wilHng.  He  is 
a  man  of  iron  will  and  constitution,  though  terribly  pulled 
down,' 

On  Mr.  F.'s  arrival  in  Leeds,  he  went  direct  to  a  surgical 
home,  his  weight  then  being  lo  stones.  He  was  then  suffering 
severe  pain,  but  was  able  to  take  a  little  milk,  which  was,  in 
fact,  the  only  form  of  food  he  had  been  able  to  digest  for  a  long 
time.  Within  a  few  hours  he  was  seized  with  violent  haema- 
temesis,  and  vomited  5  pints  of  clots  and  dark  fluid  mixed  with 
mucus.  Rectal  feeding  was  at  once  adopted,  and  an  ice-bag 
applied  to  the  epigastrium.  The  next  day  much  coffee-ground 
material  was  vomited,  and  on  the  third  day  the  bleeding  ceased. 
An  operation,  which  was  clearly  demanded,  was  arranged  for 
March  22,  but  on  the  night  of  the  21st  he  again  vomited  three 
pewters  full  of  pure  dark  blood,  which  clotted  soon  after  being 
vomited.  The  stomach  was  quite  empty  of  food,  as  after  the 
night  of  his  admission  feeding  had  been  entirely  rectal.  He  was 
now  extremely  weak,  but,  as  the  vomiting  and  bleeding  were 
continuing,  Dr.  White  agreed  with  me  that  it  would  be  better 
not  to  postpone  operation,  for  he  was  rapidly  losing  ground,  and 
clearly  could  not  stand  a  greater  loss.  An  hour  before  operation 
he  vomited  blood  freely  again.  On  the  morning  of  March  22  the 
abdomen  was  opened,  and  the  lesser  curvature  of  the  stomach 
found  to  be  much  indurated,  forming  a  tumour.  There  was  also 
much  puckering  of  the  surface  of  the  stomach,  and  the  glands  in 
the  greater  and  lesser  omentum  were  enlarged  but  discrete.  A 
posterior  gastro-enterostomy  was  performed,  a  bone  bobbin  being 
used.  In  order  to  guard  against  shock,  he  was  enveloped  in 
cotton-wool,  had  10  minims  of  liq.  strychniae  (B.P.)  given  sub- 
cutaneously  before  operation,  and  had  a  pint  of  saline  fluid,  with 
an  ounce  of  brandy,  given  into  the  bowel.  Immediately  after 
operation,  Avhich  was  finished  within  the  half-hour,  nearly  a  pint 
of  saline  fluid  was  injected  into  the  subcutaneous  tissues  of  the 
axilla,  and  another  pint,  together  with  an  ounce  of  brandy, 
administered  per  rectum.  During  the  day  three  injections  of 
5  minims  of  liq.  strychniae  were  given,  and  the  rectal  enemata 
were  repeated.  Very  little  shock  was  felt,  and  the  after-progress 
was  uninterrupted.  The  bowels  were  moved  on  the  third  day, 
and  the  wound  was  dressed  and  found  healed  on  the  loth.  No 
more  blood  was  parted  with,  and  stomach  feeding  was  begun  four 
days  after  operation.  By  the  end  of  the  week  he  was  taking  as 
much  as  5  pints  of  fluid  nourishment  in  the  twenty-four  hours. 
He  said  he  had  never  had  any  pain  since  the  operation,  and  was 
feeling  better  than  he  had  done  for  a  long  time.     He  had  lost  all 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  149 

the  acid  eructations,  the  constant  burning  at  the  epigastrium,  and 
the  flatulency. 

Four  is  not  a  large  number  of  cases  to  give  as  examples, 
but  the  treatment  of  hsematemesis  by  operation  is  a  com- 
paratively new  operation,  and  only  few  cases  have  been 
reported.  Had  it  not  been  for  the  accident  of  leakage  when 
a  Murphy  button  was  beginning  to  separate,  there  would 
have  been  no  casualty  in  the  list ;  but  that  is  an  accident 
which  can  be  avoided  by  employing  sutures  around  a  de- 
calcified bone  bobbin,  which  is  now  our  regular  custom. 
Undoubtedly,  without  operation  all  the  patients  would  have 
died.     The  cases  present  individual  points  of  interest. 

In  three  cases — the  first,  second,  and  fourth — gastro- 
enterostomy, by  securing  physiological  rest  and  freedom 
from  the  irritation  due  to  hyperacidity  of  the  gastric  juice, 
which  is  usually  present  in  ulcer  of  the  stomach,  completely 
arrested  the  bleeding. 

The  third  case  illustrated  the  feasibility  of  exploring  the 
stomach  even  in  a  patient  brought  very  low  by  excessive 
loss  of  blood  ;  and  although  the  ligature  of  the  chief  bleeding- 
points  was  effected,  it  was  deemed  advisable  to  secure  rest  to 
the  stomach  by  performing  a  posterior  gastro-enterostomy, 
especially  as  this  could  be  done  without  materially  prolong- 
ing the  operation. 


CHAPTER  X 
THE   COMPLICATIONS   OF  GASTRIC  ULCER   [continued) 

Perforating  Ulcer  of  the  Stomach. 

Perforation  of  an  acute  ulcer  of  the  stomach  is  one  of  the 
most  serious  and  appaUing  catastrophes  that  can  befall  a 
human  being. 

Perforation  may  be  acute,  subacute,  or  chronic. 

In  acute  perforation  the  giving  way  of  the  base  of  the  ulcer 
is  sudden,  and  the  contents  of  the  viscus  are  at  once  free  to 
escape  into  the  peritoneal  cavity. 

In  subacute  perforation,  which  probably  occurs  when  the 
stomach  is  empty,  or  when  some  adhesions  are  present,  or 
the  opening  is  quickly  plugged  with  omentum,  the  symptoms 
are  similar  in  kind  to,  though  less  in  degree  than,  those  of 
acute  perforation. 

In  chronic  perforation  the  process  of  ulceration  has  been 
sufficiently  languid  to  permit  of  protective  adhesions  form- 
ing, so  that  the  field  available  for  the  escaping  contents  is  a 
limited  one.  The  gradual  penetration  of  the  stomach  coats 
has  induced  a  plastic  peritonitis,  resulting  in  adhesions,  and 
a  localized  abscess  cavity  is  formed. 

Acute  and  Subacute  Perforation. 

I.  Frequency. — The  frequency  of  perforation  in  cases  of 
gastric  ulcer  has  been  variously  estimated  by  different 
writers.  The  extreme  assessments  are  6*5  and  28*5  per  cent. 
The  mean  of  all  recorded  cases  is  not  an  accurate  index 
to  the  general  liability,  for  a  very  striking  difference  is 
observed   in    the   statistics    collected   in   various   countries. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  151 

Tinker,  Finney,  and  others,  have  remarked  on  the  immunity 
which  exists  in  the  United  States.  Lebert  noticed  perfora- 
tion in  12  per  cent,  of  his  own  cases.  In  Fenwick's  own 
series  of  112  cases,  perforation  was  observed  in  28*5  per  cent., 
and  in  a  series  of  678  autopsies  in  22*8  per  cent.  Brinton 
states  that  perforation  occurs  in  from  13  to  15  per  cent.,  and 
Habershon  in  18  per  cent.  In  England  the  percentage  may 
be  stated  to  be  approximately  15  to  20. 

2.  Site  of  the  Ulcer. — The  treatment  of  perforation  of  a 
gastric  ulcer  by  operation  necessitates  as  accurate  an  esti- 
mate as  possible  of  the  locality  of  such  ulcers.  Pariser  and 
Lindner  state  that,  of  200  cases  of  gastric  ulcer,  190  will  be 
on  the  posterior  wall,  and  of  these  4  will  perforate ;  10  will 
be  on  the  anterior  wall,  and  of  these  8|  will  perforate. 
Brinton  estimated  that  70  per  cent,  of  all  perforations  occur 
on  the  anterior  surface  of  the  stomach,  21  per  cent,  on  the 
lesser  curvature,  and  only  g  per  cent,  on  the  posterior  wall. 
Ulceration  is  more  frequently  found  near  the  pylorus,  but 
perforation  is  more  common  near  the  cardiac  extremity. 
Fenwick,  from  a  study  of  operation  cases  and  post-mortem 
records,  remarks  that  '  whereas  the  acute  disease  usually 
perforates  the  comparatively  thin  coats  of  the  stomach  in 
the  cardiac  half  of  the  viscus,  close  to  the  lesser  curvature, 
and  on  the  anterior  surface,  the  chronic  form  of  the  com- 
plaint is  most  prone  to  perforate  in  the  pyloric  portion  of  the 
organ  on  the  posterior  aspect  near  the  upper  margin.'  The 
greater  liability  of  an  ulcer  of  the  anterior  wall  may  be  due 
to  the  fact  that  it  lacks  the -support  derived  from  viscera 
that  is  accorded  to  the  posterior  wall.  Protective  adhesions 
are  therefore  less  likely  to  form. 

The  ulcers  which  lead  to  perforation  may  be  multiple.  In 
20  per  cent,  of  the  recorded  cases  there  were  more  perfora- 
tions than  one.  Rarely  a  perforation  of  a  gastric  and  duo- 
denal ulcer  may  occur  together. 

3.  Sex. —  Perforation  is  seen  more  frequently  in  women, 
especially  young  women — and  among  them  in  young  servant 
girls— than  in  men.  Allowing  for  the  greater  frequency  of 
ulcer  in  women,  we  find  that  relatively  perforation  is  more 
frequent  in  men,  especially  in  men  over  the  age  of  forty. 


152  SURGERY  OF  THE  STOMACH 

4.  The  size  of  the  perforation  may  vary  widely.  In  some 
cases  the  opening  is  hardly  larger  than  a  pin-prick  ;  in  others 
it  readily  admits  two  fingers.  The  importance  of  this 
variation  is  probably  considerable.  A  small  perforation, 
especially  when  the  stomach  is  empty,  will  permit  the  least 
trickle  of  fluid,  and  will  become  readily  and  completely 
blocked  by  an  omental  plug.  A  large  perforation  occurring 
when  the  stomach  is  full  leads  to  the  flooding  of  the  cavit}' 
with  a  torrent  of  fluid  and  the  sudden  overwhelming  of  the 
peritoneum.  The  swiftness  and  suddenness  of  the  onset 
and  the  severity  of  the  symptoms  are  not  improbably 
measured,  therefore,  by  the  size  of  the  perforation  and  the 
state  of  repletion  of  the  stomach. 

Bacteriology. 

The  bacteriology  of  acute  perforation  has  been  most 
unaccountably  neglected.  Hamburger,  Kitasato,  and  others, 
have  shown  that  practically  every  pyogenic  organism  is 
found,  at  certain  times  and  under  certain  conditions,  in  the 
stomach  contents.  It  is  doubtful  whether  the  stomach  ever, 
in  usual  health,  is  sterile,  even  when  empty  or  nearly  so. 
The  gastric  juice  has  a  certain  influence  inimical  to  germ 
life,  but,  according  to  Finney,  there  are  many  organisms 
that  successfully  resist  it,  and  even  remain  for  a  longer  or 
shorter  period  in  the  deeper  layers  of  the  mucosa,  ready  to 
exert  their  baleful  influence  whenever  a  perforation  affords 
them  opportunity.  Very  few  and  very  inadequate  observa- 
tions have  been  made  upon  the  peritoneal  contents  after 
acute  perforation.  It  is  more  than  likely  that  information 
derived  from  examinations  of  the  exudate  taken  at  the  time 
of  the  operation  will  have  important  value  in  the  question 
of  prognosis.  The  condition  of  the  peritoneum,  of  the  fluid 
it  contains,  of  the  gas  escaping  from  it,  of  the  massive  clouds 
of  lymph,  is  vastly  different  from  that  seen  in  cases  of  septic 
peritonitis,  however  arising.  Yet  in  all  text-books  the  state- 
ment occurs  repeatedly  that  perforation  causes  immediate 
septic  peritonitis. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  153 

Symptoms. 

Acute  Perforation. — The  perforation  of  a  gastric  ulcer  may 
or  may  not  be  preceded  by  the  symptoms  and  signs  of  ulcera- 
tion. Symptoms  are  often  lacking  when  an  ulcer  is  situated 
on  the  anterior  wall  of  the  stomach  ;  and  as  such  an  ulcer 
is  more  liable  to  perforation,  the  absence  of  characteristic 
symptoms  is  readily  understood.  If  a  history  suggestive  of 
ulceration  can  be  obtained,  the  diagnosis  of  perforation  in 
any  abdominal  catastrophe  becomes  simpler.  In  a  certain, 
though  small,  proportion  of  cases  (about  8  per  cent.)  no 
history  of  antecedent  gastric  disablement  can  be  elicited. 

The  initial  symptom  is  almost  constantly  a  sudden,  sharp, 
stabbing  pain,  altogether  intolerable  and  overwhelming,  in 
the  epigastrium.  Not  seldom  the  patient  remarks  that  some- 
thing '  has  given  way '  in  the  abdomen,  and  a  feeling  as  of 
the  trickling  or  gushing  of  fluid  may  be  remarked.  The  pain 
may  be  limited  in  area,  or  may  radiate  to  the  shoulders  or 
interscapular  region ;  rapidly  it  invades  the  whole  abdomen. 
There  is  immediately,  or  within  a  very  few  moments,  a  con- 
dition of  collapse  of  varying  profundity,  but  generally  most 
severe.  The  face  is  drawn,  and  the  expression  tells  of  agony 
and  anxiety  and  of  the  fear  of  present  or  impending  disaster. 
The  surface  of  the  body  is  pale,  and  cold,  and  clammy,  the 
lips  livid,  the  face  blanched,  and  there  is  a  tinge  of  blueness 
in  all  the  skin.  The  respiration  is  shallow  and  hurried,  the 
pulse  rapid,  thin,  or  almost  imperceptible.  Vomiting,  with 
or  without  bleeding,  is  an  inconstant  symptom.  Finney 
iinds  it  recorded  in  40  per  cent,  of  cases,  Fenwick  in  29  per 
cent.  Probably  its  occurrence  depends  upon  the  amount  of 
fluid  in  the  stomach,  the  size  of  the  ulcer,  and  the  depth  of 
the  collapse.  Traube  explains  its  infrequency  as  being  due 
to  the  ease  with  which  the  contents  escape  through  the  gap 
made  by  the  ulcer,  an  explanation  which  is  in  no  degree 
convincing.  Thirst  is  urgent,  distressing,  and  unquenchable. 
The  urine  is  scanty,  and  may,  indeed,  be  wholly  suppressed. 
At  the  first  the  abdomen  is  hard  and  retracted,  the  muscles 
tight  and  fixed  as  a  protecting  and  unyielding  splint,  ensur- 
ing rest.     Gradually,  however,  the  abdomen   fills  with  gas 


154  SURGERY  OF  THE  STOMACH 

and  fluid,  and  a  bulging  of  its  walls  is  seen.  Liver  dulness 
is  then  generally  absent,  but  its  presence  or  absence  is  void 
of  any  significance,  and  is  unreliable  as  an  aid  to  diagnosis. 
The  whole  abdomen,  but  more  especially  the  upper  half,  is 
tender,  and  the  patient  shrinks  from  the  contact  of  the 
surgeon's  hand.  Death  may  occur  during  the  stage  of 
collapse  (in  4  per  cent.,  Fenwick).  In  rare  cases  death  may 
seem  almost  instantaneous.  If  the  patient  rallies,  the 
symptoms  and  the  signs  are  those  of  general  peritonitis. 
The  severity  of  the  instant  shock  and  of  the  subsequent 
peritoneal  reaction  varies  within  wide  limits,  and  is  doubt- 
less dependent  upon  the  size  and  position  of  the  perforation, 
the  character  and  quantity  of  food  in  the  stomach,  and  the 
severity  of  the  vomiting.  The  sudden  incidence  of  a  marked 
leucocytosis  is  considered  an  important  diagnostic  sign  by 
Finney.  That  it  is  not  always  reliable  has  been  shown  in 
several  cases.  Its  precise  worth  and  significance  must  be 
determined  by  future  observation. 

Subacute  Perforation.  ■ —  Subacute  perforation  probably 
occurs  when  the  stomach  is  empty  or  nearly  so,  or  when  a 
few  filmy  adhesions  have  formed  which  check  the  rapidity 
of  the  peritoneal  invasion.  The  symptoms  are  of  the  same 
type  as  those  described,  but  they  are  less  brusque  in  their 
onset  and  throughout  less  vivid.  There  will  be  pain,  sharp 
and  stabbing,  followed  by  sickness,  faintness,  and  a  degree 
of  collapse.  All  these  are  much  less  marked  than  in  the 
acute  form,  though  they  may,  at  the  end  of  two  or  three 
days,  develop  rapidly,  and  end  the  patient's  life  in  a  few 
hours.  Subacute  perforation  implies  a  less  extensive,  as  well 
as  a  less  acute,  infection  of  the  peritoneum.  In  some  cases 
there  may  be  a  gradual  merging  into  those  classed  as 
'  chronic,'  where,  inflammation  being  limited  in  area,  a 
localized  abscess  forms.  (For  examples  see  section  on 
Gastrolysis.) 

Differential  Diagnosis. 

The  conditions  likely  to  be  mistaken  for  acute  perforating 
ulcer  of  the  stomach  are  those  which  result  from  sudden 
intraperitoneal  disasters.     Such  are  acute  perforating  ulcer 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  155 

of  the  duodenum,  ruptured  tubal  gestation,  acute  intestinal 
obstruction,  acute  haemorrhagic  pancreatitis,  thrombosis  of 
the  superior  mesenteric  vein,  and  acute  perforative  appendi- 
citis. When  ulcers  of  the  pyloric  antrum  or  of  the  duodenum 
perforate,  the  visceral  contents  will  run  downwards  to  the 
right  iliac  fossa,  and,  there  setting  up  peritonitis,  may  cause 
symptoms  which  mimic  with  remarkable  success  those 
resulting  from  acute  appendicitis.  Other  conditions  which 
may  resemble  perforating  ulcer  in  their  symptoms  are  on- 
coming pneumonia,  with  its  sudden  pleuritic  pain ;  acute 
poisonings ;  acute  dilatation  of  the  stomach  ;  and  acute 
inflammatory  conditions  in  the  gall-bladder.  A  minute 
examination  of  the  patient  and  a  careful  attention  to  the 
history  will  enable  a  correct  diagnosis  to  be  made  in  nearly 
all  the  cases.  The  fact  that  in  92  per  cent,  a  previous 
history  of  gastric  ulceration  can  be  obtained  is  helpful,  but 
may  be  misleading. 

The  two  following  cases  may  usefully  be  contrasted  and 
compared.  In  the  first  a  perforating  gastric  ulcer  resembled 
in  its  symptoms  a  case  of  extra-uterine  gestation,  and  in  the 
second  an  extra-uterine  gestation  had  to  be  distinguished 
carefully  from  a  perforating  gastric  ulcer. 

Perforating    Gastric    Ulcer    simulating    Rupture    of 
Extra-uterine  Gestation.     Operation  ;  Recovery. 

On  January  18,  1899,  one  of  us  (Mayo  Robson)  was  asked  to 
see  a  patient  at  the  Station  Hotel,  Leeds,  and  to  come  prepared 
to  operate  for  probable  rupture  of  an  extra-uterine  gestation. 
The  history  given  was  that  the  patient,  Mrs.  P.,  aged  twenty- 
nine,  had  been  suddenly  seized  at  the  station  with  acute  ab- 
dominal pain,  followed  immediately  by  collapse,  in  which  con- 
dition she  was  removed  to  the  hotel. 

Her  last  regular  '  period '  had  occurred  seven  weeks  previously, 
and  having  missed  the  next  '  period,'  and  thinking  herself  to  be 
pregnant,  she  took  an  ecbolic  five  days  previously,  which  brought 
on  severe  gastro-intestinal  disturbance  and  fainting.  Three  days 
later — that  is,  two  days  before  the  attack  in  question — she  had 
had  some  uterine  haemorrhage,  but  no  stomach  symptoms  com- 
plained of ;  and  it  was  only  on  close  inquiry  later  that  any  history 
of  indigestion  was  obtained.  Dr.  Macrae  saw  her  four  hours 
after,  and  found  liver  dulness  present.      No  abdominal  disten- 


156  SURGERY  OF  THE  STOMACH 

sion  ;  no  rigidity  of  recti ;  some  fulness  in  left  loin  and  tenderness 
over  left  ovary.  On  vaginal  examination  there  was  fulness  in 
Douglas's  pouch  and  an  indefinite  fulness  in  the  left  fornix.  When 
we  saw  her  later  the  pulse  was  130  and  she  was  pallid  and  col- 
lapsed. A  diagnosis  of  rupture  of  an  extra-uterine  gestation  was 
made,  and  the  abdomen  opened  above  the  pubes,  when  odourless 
gas  escaped  and  a  little  fluid.  The  small  suprapubic  incision  was 
therefore  closed,  and  one  made  above  the  umbilicus,  when  a  small 
perforation  was  discovered  in  the  centre  of  a  large  chronic  ulcer 
near  the  cardiac  end  of  the  stomach,  close  to  the  upper  border  on 
the  anterior  surface.  The  edges  of  the  ulcer  were  refreshed  and 
brought  together  by  sutures,  but,  as  the  tissues  were  very  friable, 
an  omental  graft  was  sutured  over  the  line  of  incision.  The 
abdomen  was  wiped  clean  after  the  evacuation  of  a  quantity  of 
turbid  fluid  from  the  right  renal  pouch  and  the  space  between  the 
liver  and  the  diaphragm.  A  small  gauze  drain  was  employed, 
but,  as  the  sequel  proved,  was  needless,  and  it  was  removed  the 
next  day.  Recovery  was  uninterrupted,  and  she  returned  home 
February  16. 

She  is  now,  and  has  been  since,  quite  well. 

In  the  following  case,  under  the  care  of  Dr.  Johnstone,  of 
Ilkley,  the  symptoms  of  perforation  of  gastric  ulcer  were 
mimicked  to  a  degree  which  rendered  diagnosis  difficult : 

Mrs.  C.  D.,  aged  twenty-two,  married  twelve  months,  was 
seized  suddenly  with  acute  abdominal  pain  and  collapse.  There 
was  a  history  of  pain  after  food,  and  occasional  vomiting,  which 
might  have  been  due  to  gastric  ulcer  or  early  pregnancy.  A 
'  period '  due  three  weeks  before  the  sudden  attack  had  been 
missed.  The  shock  was  combated  with  strychnine  and  digitalis. 
Dr.  Johnstone,  diagnosing  a  ruptured  tubal  gestation,  called 
Dr.  Scott  and  Mr.  Jessop  in  consultation.  The  problematical 
history  of  gastric  ulcer,  a  long-standing  anaemia,  the  general  dis- 
tension of  the  abdomen,  with  tympany,  and  the  absence  of  liver 
dulness,  were  considered  suggestive  of  perforating  gastric  ulcer. 
An  incision  was  made  above  the  pubes,  however,  and  a  ruptured 
tube  discovered  and  removed. 

Treatment. 

There  can,  we  think,  be  no  doubt  that  acute  perforating 
ulcer  of  the  stomach  does  occasionally  heal  spontaneously. 
We  have  on  three  or  four  occasions  at  least,  in  operating 
for  various  pathological  conditions  of  the  viscus,  found  ample 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  157 

evidence  of  such  in  the  guise  of  old  peritonitis  around  and 
upon  the  stomach.  Dense  and  widespread  adhesions  to  the 
liver  or  abdominal  wall  are  found,  and  on  separating  these 
the  stomach  may  be  opened  at  the  site  of  an  old  ulcer  in  the 
anterior  wall.  In  these  cases,  on  subsequent  inquiry,  a  clear 
history  of  some  sudden  catastrophe  has  been  elicited — a 
catastrophe  that  doubtless  occurred  at  the  time  of  perfora- 
tion, and  probably  ended  happily  only  because  of  the  empty 
condition  of  the  stomach  at  the  moment  of  rupture.  Pariser 
has  collected  fourteen  cases,  and  Hall  six  cases,  of  apparent 
perforation  ending  in  recovery.  But  though  such  cases  do 
exist,  they  form  but  a  trifling  proportion,  and  have  been 
computed  at  the  most  at  5  per  cent,  of  the  whole  number. 
Their  occurrence,  therefore,  is  no  argument  against  the  law  of 
invariable  and  immediate  operation  in  all  diagnosed  cases. 

There  are  cases  in  which,  owing  to  an  absence  of  clearly- 
cut  and  unmistakable  symptoms  and  signs,  a  doubt  may 
exist  in  the  mind  of  the  surgeon  as  to  the  diagnosis,  A 
perforation  may  be  suspected,  but  a  little  hesitation  is 
felt  in  proceeding  at  once  to  operation.  In  such  a  dilemma 
resource  may  be  had  to  the  'lesser  abdominal  section,'  the 
exploratory  incision.  This  procedure  has  been  strongly 
advocated  by  Mikulicz,  Mayo  Robson,  Kocher,  and  Finney, 
and  should  be  carried  out  under  cocaine  anaesthesia.  An 
incision  large  enough  to  admit  the  linger  is  made,  and  is 
ample  for  purposes  of  investigation  and  diagnosis.  If  the 
exploration  prove  negative,  no  harm  is  done,  no  shock  is 
felt,  and  the  patient  is  none  the  worse ;  if  the  exploration 
prove  positive,  the  incision  may  be  extended  under  cocaine 
anaesthesia,  or  ether  may  be  given. 

Operation. — The  first  surgeon  to  advise  and  adopt  operative 
intervention  in  perforation  of  agastric  ulcer  was  Mikulicz,  then 
Billroth's  assistant,  in  1880.  The  first  successful  operation 
was  performed  in  1892  by  Kriege  [Berl.  Klin.  Wocli.,  De- 
cember, 1892).  One  of  the  first  cases  in  England,  operated 
upon  three  days  after  perforation,  was  under  Mayo  Robson, 
in  the  Leeds  Infirmary. 


158  SURGERY  OF  THE  STOMACH 

Perforating  Gastric  Ulcer  operated  ox  in  1888. 

One  of  us  (Mayo  Robson)  operated  on  a  girl,  aged  seventeen, 
at  the  Leeds  Infirmary  in  1888,  on  October  18. 

Unfortunately,  the  operation  was  not  performed  until  the  third 
day,  when  peritonitis  was  general. 

The  abdomen  was  flushed  out  and  drained  by  a  glass  tube  in 
the  pelvis. 

The  perforation  was  the  size  of  a  shilling  in  the  anterior  surface 
of  the  stomach,  and  in  a  most  favourable  place  for  treatment, 
which  was  unfortunately  adopted  too  late.  Death  occurred  a 
few  hours  later. 

An  incision  4  inches  long  is  made  in  or  near  the  middle 
line  of  the  abdomen,  above  the  umbilicus.  This  may  later 
need  enlargement  upwards,  downwards,  or  obliquely,  in 
order  to  permit  free  access  to  the  ruptured  point.  As  soon 
as  the  abdomen  is  opened,  a  rapid  survey  of  the  whole 
stomach  surface  is  made.  It  is  well  to  begin  at  the  cardiac 
end,  for  it  is  here  that  perforation  is  most  frequent.  The 
left  costal  margin  is  well  dragged  upwards  by  an  assistant, 
and  gentle  traction  on  the  stomach  is  made,  in  order  to 
bring  the  fundus  well  into  view.  If  the  anterior  surface 
is  sound,  the  great  omentum,  immediately  below  the  greater 
curvature,  is  torn  open  to  an  extent  sufficient  to  admit  the 
index-finger,  which  then  explores  the  posterior  surface ;  or 
the  great  omentum  is  lifted  up  and  the  transverse  meso- 
colon torn  through,  so  as  to  open  up  the  lesser  sac,  and 
bring  into  view  the  posterior  surface  of  the  stomach.  A 
massive  outpouring  of  lymph  on  the  surface  of  the  stomach 
affords  generally  a  useful  guide  to  the  perforation.  These 
flakes  and  bands  are  protective  in  character,  and  are  densest 
in  the  area  where  most  they  are  needed.  On  gently  breaking 
through  them,  the  ulcer  will  be  exposed.  When  found,  the 
perforation  must  be  closed  as  speedily  as  possible.  The 
ulcer  may  or  may  not  be  excised.  There  is  probably  no 
advantage  in  removing  it,  and  a  little  time  is  wasted  in  so 
doing.  The  orifice,  if  small,  may  be  closed  by  a  purse-string 
suture.  If  more  than  a  puncture,  it  should  be  closed  by  at 
least  two  layers  of  continuous  sutures.  If  the  walls  of  the 
stomach  are,  as  is  not  seldom  the  case,  easily  lacerable,  an 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  159 

interrupted  suture,  or  Halsted's  mattress  suture,  is  prefer- 
able. Tliere  are,  though  rarely,  cases  where,  owing  to 
excessive  destruction  of  the  wall  or  inaccessibility  of  the 
ulcer,  the  perforation  cannot  be  stitched  up.  In  such  the 
omentum  may  be  used  to  close  the  gap.  Enderlen's  experi- 
ments and  those  of  Sundholm  show  that  the  omentum 
not  only  acts  efficiently,  but  permits  a  subsequent  restora- 
tion, apparently  complete,  of  the  stomach  wall.  In  place  of 
omentum,  an  adjacent  coil  of  intestine  may  be  stitched  along 
the  gap,  and  will  effectually  close  it.  If  neither  of  these 
methods  can,  for  any  reason,  be  adopted,  the  best  course  is 
to  drain  the  cavity  freely  by  passing  strips  of  gauze,  or  an 
indiarubber  tube,  or  both,  down  to  the  ulcer. 

After  the  perforation  has  been  dealt  with,  the  general 
peritoneal  cavity  must  be  cleansed  as  thoroughly  as  time 
will  permit  by  sponging  or  hot  flushing. 

Flushing  is  generally  necessary  to  insure  cleanliness. 
Sterile  salt  solution  at  a  temperature  of  105°  is,  on  the 
whole,  the  most  satisfactory  fluid.  It  should  be  introduced 
with  the  help  of  a  glass  funnel  and  a  length  of  indiarubber 
tubing.  The  tube  may  readily  be  guided  to  all  the  peri- 
toneal recesses,  which  should  be  filled  to  free  overflowing 
with  the  solution.  Especial  pains  should  be  taken  to  flush 
the  space  between  the  liver  and  the  diaphragm,  the  kidney 
pouches,  the  iliac  fossae,  and  the  pelvis.  Flushing  should  be 
continued  until  the  fluid  returns  clear.  There  is  then  no 
need  to  empty  the  peritoneal  cavity,  for  the  fluid  is  rapidly 
absorbed,  and  is  probably  beneficial.  In  all  cases  a  drainage- 
tube  should  be  passed  down  into  the  pelvis  through  an 
incision  made  just  above  the  pubes. 

If  general  septic  peritonitis  has  developed,  the  following 
plan,  advocated  by  Finney,  may  be  adopted :  One  or  more 
incisions,  free  enough  to  allow  an  examination  of  the  entire 
peritoneal  cavity,  should  be  made.  Through  this  the  intes- 
tinal coils  are  withdrawn  sufficiently  to  allow  the  operator  to 
evacuate  any  peritoneal  exudate,  and  thoroughly  cleanse 
with  warm  salt  solution  and  gauze  pledgets  all  recesses  and 
folds.  The  intestinal  coils,  which  should  be  kept  covered  by 
an  assistant  with  warm,  soft  sponges  or  towels  during  this 


i6o  SURGERY  OF  THE  STOMACH 

manceuvre,  should  then  be  cleansed  as  far  as  possible  from 
exudate  and  lymph  by  irrigation  and  wiping  with  pledgets  of 
gauze,  and  replaced  in  the  abdominal  cavity.  Too  much 
time  should  not  be  consumed  in  the  cleansing,  nor  should 
the  intestines  be  handled  roughly,  but  it  is  difficult  to 
exercise  too  much  care  in  the  peritoneal  toilet. 

As  perforation  in  20  per  cent,  of  the  recorded  examples  has 
occurred  at  two  or  more  points,  the  surgeon  should  not  be 
content  with  suture  of  the  first  ulcer  discovered,  but  should 
satisfy  himself  that  the  stomach  elsewhere  is  sound. 

Prognosis. 

The  prognosis  in  ruptured  ulcer  of  the  stomach  will  largely 
depend  upon : 

1.  The  condition  of  the  stomach,  whether  full  or  empty. 

2.  The  time  elapsing  between  perforation  and  operation. 

3.  The  size  and  number  of  the  perforations. 

4.  The  presence  or  absence,  and  the  severity,  of  the 
vomiting. 

1.  The  condition  of  the  stomach,  whether  full  or  empty.  If 
the  stomach  has  been  recently  filled,  the  food  will  be  in  solid 
particles  of  varying  size,  and  will  contain  a  variety,  in  number 
and  character,  of  micro-organisms.  Under  such  circum- 
stances a  perforation  will  probably  be  large,  and  will  permit 
an  escape  of  material  of  a  kind  best  calculated  to  cause  an 
intense  peritoneal  reaction.  Symptoms  will  be  of  the  acutest 
character,  shock  will  be  profound,  and  life  will  be  seriously 
imperilled.  If,  on  the  other  hand,  the  stomach  is  empty, 
there  will  be  an  escape  of  a  little  gastric  secretion  only, 
and  the  perforation  will  almost  certainly  be  small.  A  little 
local  peritonitis  may  alone  result,  symptoms  will  be  less 
aggressive,  and  recovery  will  follow.  Such  are  probably 
the  circumstances  in  cases  like  those  already  mentioned  by 
Pariser  and  Hall. 

2.  The  Time  elapsing  between  Perforation  and  Operation. — 
This  is  an  element  of  conspicuous  importance.  The  study 
of  a  large  number  of  cases  proves,  beyond  the  possibility  of 
question,  that  the  shorter  the  period  between  the  perforation 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  i6i 

and  operation,  the  greater  the  chances  of  success.  The 
operations  performed  in  each  succeeding  period  of  twelve 
hours  after  perforation  have  a  gradually  increasing  mortality, 
as  shown  in  the  accompanying  table  : 


Total 
Cases. 

Recovered . 

Died. 

Percentage 
of  Deaths. 

Under  12  hours  ... 

••       49 

35 

14 

28-5 

From  12  to  24  hours 

••       33 

12 

21 

63-6 

„      24  to  36      „ 

16 

2 

14 

87-5 

„      36  to  48      „ 

2 

— 

2 

loo-o 

Over  48  hours     ... 

■=       33 

16 

17 

5-^-5 

The  fact  that  the  mortality  from  operation  diminishes  in 
those  dealt  wath  more  than  forty-eight  hours  after  operation 
is  readily  explained.  In  such  cases  the  perforation  will 
almost  certainly  have  been  subacute,  for  the  ordinary  acute 
case  is  always  moribund  at  the  end  of  forty-eight  hours. 

3.  The  Size  and  Number  of  the  Perforations. — If  there  is  but 
one  perforation,  and  that  a  small  one,  the  condition  is, 
symptomatically,  subacute.  If  there  are  more  perforations 
than  one,  and  if  any  of  these  are  large,  the  symptoms  are 
the  acutest  conceivable. 

4.  The  Presence  or  Absence  and  the  Severity  of  the  Vomiting. 
— Vomiting  is  present  in  29  per  cent.  (Fenwick)  or  40  per 
cent.  (Finney)  of  the  cases.  At  each  act  of  vomiting,  the 
stomach  contents  are  ejected  not  only  through  the  cesophagus, 
but  through  the  perforation  also.  The  more  severe  the 
vomiting,  the  greater  the  amount  of  the  stomach  contents 
thrown  into  the  peritoneal  cavity,  and,  concomitantly,  the 
more  severe  the  peritoneal  reaction  thereby  induced. 

Results. 

There  are  few  matters  so  difficult  to  deal  with  statistically 
as  this.  It  is  probable  that  the  vast  majority  of  successful 
cases  are  recorded,  for  each  one  is  a  triumph  of  surgical  skill, 
each  one  indisputably  means  a  life  saved.  On  the  other 
hand,  in  operating  upon  an  unsuccessful  case,  the  surgeon 
feels  that  he  has  merely  made  a  powerless  interference  in  the 
course  of  a  certainly  fatal  disaster,  and  the  record  is  con- 
signed to  oblivion. 

It   is,  nevertheless,  necessary  to  have   some   figures  upon 

II 


1 62  SUJ?GERY  OF  THE  STOMACH 

which  to  base  our  statements  of  prognosis.  In  order  to  have 
a  statistical  basis,  we  have  added  to  the  cases  tabulated  by 
Mayo  Robson  in  the  Hunterian  Lectures  the  case  of  Finney 
{Annals  of  Surgery,  July,  1900),  and  cases  of  Moynihan, 
Christy  Wilson,  Littlewood  (additional),  Musser  and  Whar- 
ton, Maunsell,  Selby,  Hume,  Moore,  and  Kellock  (Lancet, 
1900).  The  total  number  is  486.  Among  these  were 
227  recoveries  and  259  deaths,  equivalent  to  a  recovery  of 
44*6  per  cent.  In  the  statistics  of  Tinker  {Philadelphia 
Medical  Journal,  February,  1900),  it  is  shown  that  during  the 
three  previous  years,  of  all  cases  recorded,  8378  per  cent, 
had  recovered  after  operation.  This  estimate  is  altogether 
too  sanguine. 

We  consider  that,  taking  the  early  cases  with  the  late,  the 
good  with  the  bad,  a  percentage  recovery  of  40  to  50  is 
probably  the  mean. 

The  following  example  of  successful  operation  for  per- 
forating gastric  ulcer  may  well  be  quoted,  for  the  patient  has 
since  been  frequently  in  attendance  upon  our  surgical  cases : 

Perforating  Gastric    Ulcer.     Operation  ;  Recovery. 

On   May  16,   1897,  o^®  °f  ^^  (Mayo   Robson)  was  asked   by 

Dr.  F.  H.  Mayo  to  see  Miss  ,  a  nurse,  aged  twenty-four, 

who,  while  nursing  an  elderly  lady,  was  suddenly  seized  with 
acute  pain  in  the  upper  abdominal  region  without  any  preliminary 
symptoms  except  indigestion,  to  which  she  had  been  subject  for 
some  years.  Her  symptoms  were  very  acute,  and  within  a  few 
hours  her  abdomen  became  distended,  and  there  was  evidence  of 
fluid  in  the  flanks  and  in  the  pelvis.  The  attack  came  on  imme- 
diately after  breakfast,  when  the  stomach  was  full  of  tea,  bread- 
and-butter,  etc. 

Operation  at  10  p.m.,  sixteen  hours  after  rupture.  Chronic 
ulcer  with  perforation  the  size  of  a  sixpence  found  near  lesser 
curvature  on  the  anterior  surface  near  the  cardiac  orifice. 

Edges  of  ulcer  refreshed  and  brought  together  by  sutures  ; 
omental  graft  applied. 

Lavage  of  abdomen  with  hot  saline  solution.  Suprapubic 
drainage  for  several  days. 

Recovery  delayed  by  an  attack  of  left-sided  pleurisy,  but 
ultimately  perfect,  and  she  is  now  and  has  since  been  quite  well, 
and  has  performed  her  duties  as  a  nurse  ever  since  her  recovery. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER 


163 


Perigastric  Abscess. 

Perigastric  abscesses  result  chiefly  from  perforating  ulcers 
of  the  stomach.  They  may  in  occasional  examples  be  due 
to  causes  originating  elsewhere  than  in  the  stomach,  but 
such  matters  do  not  now  concern  us. 

Ulceration  of  the  stomach  leading  to  perigastric  abscess 
may  be  of  varying  degrees  of  activity.  In  by  far  the  great 
majority  the  ulcerative  process  has  been  dilatory,  and  has 


Fig.  36. — Pyopneumothorax. 

permitted  the  formation  of  limiting  adhesions ;  but  acute 
perforation,  subacute  perforation,  and  acute  "perforation 
operated  upon  but  imperfectly  drained,  may  all  give  rise  to 
localized  abscess. 

Perigastric  abscesses  so  arising  may  have  any  conceivable 
relation  to  the  stomach,  and  may  vary  considerably  in 
intensity  and  acuteness.  In  a  minority  of  cases  a  circum- 
scribed swelling  results,  situated  most  commonly  in  the  left 
hypochondriac  region,  or  to  the  left  of  the  middle  line,  in 
the  epigastrium.  As  such  an  abscess  slowly  enlarges,  it  may 
soften  the  skin  and  cause  it  to  break  down,  or  rupture  may 
take  place  into  one  of  the  hollow  viscera  in  the  abdomen, 

II — 2 


i64  SURGERY  OF  THE  STOMACH 

or   through    the    diaphragm  into  the   pleural   or  pericardial 
cavities. 

Owing  to  the  frequency  with  which  perforating  ulcers  of 
the  stomach  are  found  in  definitely  localized  situations,  the 
abscesses  therefrom  resulting  are  localized  also  in  well- 
recognised  areas.  The  commonest  of  all  positions  is  beneath 
the  diaphragm,  when  a  subphrenic  abscess — the  'pyopneumo- 
thorax subphrenicus  '  of  Leyden — forms.  In  179  cases  of 
subphrenic  abscess  collected  by  Maydl,  20  per  cent,  were 
due  to  perforation  ulcers  of  stomach  and  duodenum.  The 
clinical  and  pathological  conditions  resulting  from  subphrenic 
abscess  vary  so  widely  that  it  is  almost  impossible  to  present 
a  clearly-defined  symptom  group  as  characteristic  of  the 
condition.  Godlee  {British  Medical  Journal,  igoo)  says : 
'  Think  only  of  such  a  case  as  that  of  a  very  chronic  ulcer 
of  the  stomach  which  has  caused  extensive  adhesions  between 
the  viscus  and  the  diaphragm ;  an  abscess  may  form  amongst 
these  adhesions,  and  burrow  about  by  complicated  and 
narrow  tracks  until  it  points  perhaps  through  an  intercostal 
space.  Then  contrast  it  with  one  in  which  a  sudden  perfora- 
tion of  a  stomach  ulcer  has  occurred,  but  in  which  the 
suppuration  is  to  some  extent  localized  and  contains  air.  It 
is  difficult  to  trace  a  family  resemblance  between  these  two 
conditions.' 

A  subphrenic  abscess  may  be  defined  as  any  collection  of 
pus,  or  gas  and  pus,  which  as  a  whole  or  in  part  intervenes 
between  the  diaphragm  and  the  structures  normally  in 
contact  with  it.  Such  abscesses  are  anterior,  resulting  from 
perforation  of  the  anterior  wall,  and  posterior. 

Anterior  abscesses  may  form  between  the  right  lobe  of  the 
liver  and  diaphragm,  to  the  right  of  the  falciform  ligament, 
or  between  the  left  lobe  and  the  diaphragm,  to  the  left  of  the 
falciform  ligament.  The  lower  boundary  in  both  cases  is 
formed  by  adventitious  adhesions,  the  result  of  a  massive 
outpouring  of  lymph. 

Posterior  abscesses  are  contained  within  the  limits  of  the 
lesser  sac  of  peritoneum  ;  or,  having  caused  adhesion  of  the 
opposing  layers  of  the  sac,  pus  may  accumulate  in  the  retro- 
peritoneal tissue. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  165 

Symptoms. 

The  following  account  may  be  held  to  portray  with  general 
accuracy  an  average  case  of  this  kind.  At  the  first  there 
are  the  warnings  of  chronic  perforation  :  Pain  sudden  and 
sharp,  faintness,  short  and  hurried  and  painful  breathing. 
Tenderness  is  noticed  on  the  upper  part  of  the  abdomen, 
with  irregular,  but  generally  constant,  elevations  of  tempera- 
ture, and  occasionally  rigors.  The  case  may  now  assume 
the  aspect  of  an  acute  thoracic  condition,  and  pleurisy, 
pericarditis,  or  empyema,  may  develop  and  speedily  terminate 


Fig.  37. — 'Pyopneumothorax  Subphrexicus' :    Subphrenic  Abscess. 

the  patient's  life.  In  the  absence  of  these  complications, 
the  symptoms  may  quietly  continue.  There  will  be  occa- 
sional vomiting,  frequent  attacks  of  coughing ;  dyspnoea  will 
be  persistent,  and  at  times  distressing  ;  there  will  be  loss  of 
flesh,  sweating  at  night,  and  all  the  symptoms  of  a  persisting 
septic  absorption.  The  pus,  gradually  increasing  in  quantity, 
collects,  and  alone,  or  mixed  with  gas,  bulges  outwards  the 
lower  part  of  the  chest,  and  pushes  upward  the  wing  of  the 
diaphragm.  So  the  heart  may  be  tilted,  and  its  apex  beat 
felt  a  couple  of  inches  higher  than  the  normal.  The  lung 
also  is  compressed,  and  the  percussion-note  over  it  may  be 


1 66 


SURGERY  OF  THE  STOMACH 


dulled.  The  resemblance  to  a  pleuritic  effusion  may  be 
striking  and  misleading,  but  the  following  points  should 
enable  a  distinction  to  be  made  :  (i)  The  movements  of  the 
chest  are  not  impaired  on  the  affected  side ;  (2)  the  upper 
limit  of  dulness  is  not  so  sharply  defined ;  and  (3)  breath- 
sounds  may  be  heard  below  the  level  of  the  dulness,  and  if  a 


Fig.  38. — Posterior  Perigastric 

Abscess. 


Fig.  39.  —Anterior  Perigastric 

Abscess. 


deep  inspiration  be  made,  the  line  at  which  the  breath- 
sounds  and  vocal  resonance  are  heard,  and  at  which  vocal 
fremitus  is  felt,  is  distinctly  lowered.  (See  Figs.  36  and  37.) 
The  '  diaphragm  phenomenon,'  to  which  much  attention 
has  been  paid,  is  the  existence  of  a  shallow  depression  which 
moves  with  respiration  and  crosses  the  intercostal  spaces  of 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  167 

the  left  side  as  the  diaphragm  ascends  and  descends.  On 
palpation  of  the  upper  region  of  the  abdomen  a  collection 
of  fluid  may  be  felt.  Greig  Smith  drew  especial  attention  to 
the  significance  of  a  line  or  band  of  induration  and  resist- 
ance, felt  through  the  abdominal  wall,  moving  with  respira- 
tion. This  band  is  due  to  the  presence  of  adhesions  which 
limit  the  abscess  cavity  below.  In  the  assured  absence  of 
tubercular  peritonitis,  Greig  Smith  believed  this  sign  to  be 
pathognomonic  of  subphrenic  abscess.  When  gas  is  present  in 
the  cavity,  a  tympanitic  note  will  be  obtained  over  the  front 
of  the  left  side  of  the  chest,  extending  as  high  up  as  the 
fourth  rib,  or  even  higher,  the  whole  cardiac  area  being 
resonant.  On  auscultation  the  vesicular  murmur  will  be 
heard  in  the  upper  part  of  the  chest ;  below  the  fourth  rib, 
or  thereabouts,  there  will  be  amphoric  breathing.  At  the 
upper  part  of  the  abdomen  metallic  tinkling  can  be  heard, 
and  a  loud  succussion  splash  is  produced  by  jerky  move- 
ments of  the  body.  Over  the  area  of  hyper-resonance  the 
bruit  d'airain  may  be  heard.  When  the  perforation  is  on 
the  posterior  wall  of  the  stomach,  the  lesser  sac  of  the  peri- 
toneum may  be  filled  with  the  extravasated  contents.  Pus 
rapidly  forms,  and  the  foramen  of  Winslow  is  closed  by 
plastic  adhesions.  A  case  of  this  kind  is  recorded  by  Chiari 
{Wien.  Med.  Woch.,  1876)  in  which  the  pancreas,  sequestered 
by  the  inflammatory  process,  floated  in  the  pus  of  the  abscess 
cavity.  In  such  a  case  physical  signs  may  be  wholly  lacking, 
or  a  tender  swelling  may  be  noticed  in  the  umbilical  region 
and  lower  epigastric,  which  is  dull  on  deep  percussion,  and 
has  a  varying  area  of  resonance  over  it.  The  extremely 
foetid  contents  of  such  an  abscess  may  be  vomited,  and  in 
the  vomit  may  be  recognised  shreds  of  dead  tissue. 

The  abscess,  after  its  definite  localization  and  its  hemming 
in  by  adhesions,  may  assume  an  acuter  aspect  and  burrow 
upwards  or  downwards,  bursting  into  the  lung,  into  the 
pleura  (causing  pyo-pneumothorax),  into  the  pericardium, 
or,  rarely,  into  any  of  the  hollow  viscera  of  the  abdomen. 
Surface  perforation  is  occasionally  seen,  the  abscess  pointing 
and  bursting  through  the  abdominal  or  thoracic  walls.  In 
this   manner   the   gastric   fistulge,   internal    or   external,   are 


1 68  SURGERY  OF  THE  STOMACH 

formed.  If  a  retroperitoneal  abscess  form,  the  pus  may 
burrow  widely,  and  an  abscess  may  point  in  the  loin,  or 
groin,  or  anterior  abdominal  wall,  as  in  the  following : 

Retroperitoneal  Abscess  due  to  Chronic  Gastric  Ulcer. 

One  of  us,  Mayo  Robson,  saw  a  case  in  August,  1899,  in  a 
Avoman  of  thirty-three  in  which  there  was  an  abscess  in  the  retro- 
peritoneal cellular  tissue  coming  after  a  protracted  illness,  accom- 
panied by  digestive  disturbances  and  occasional  vomiting. 

The  abscess  certainly  communicated  with  the  stomach,  as, 
when  it  was  opened  and  drained  in  the  left  iliac  region,  pus  of 
the  same  odour  and  the  same  character  in  every  respect  was 
vomited.  At  the  same  time,  there  was  dulness  over  the  lower 
part  of  the  thorax  on  the  left  side,  and  some  pleurisy,  though  the 
fluid  in  the  pleural  cavity  cannot  have  been  pus,  as  it  gradually 
disappeared  after  the  abscess  was  drained. 

The  patient  improved  very  much  after  the  drainage  of  the 
abscess,  and  in  about  six  weeks  the  tube  was  left  out. 

The  patient  died  on  the  eighth  week,  when  apparently  doing 
well,  she  having  been  seen  only  an  hour  before  death,  which 
occurred  from  sudden  heart  failure. 

Unfortunately,  an  autopsy  could  not  be  obtained,  so  that  there 
must  necessarily  be  a  doubt  as  to  whether  the .  abscess  was 
dependent  on  chronic  ulcer  perforating  the  stomach  gradually 
after  adhesions  had  formed  between  the  peritoneal  layers  in  the 
lesser  sac,  or  whether  the  abscess  burst  into  the  stomach  by  ulcer- 
ation from  without. 

The  diagram  shows  the  course  of  the  pus  in  this  case  to  have 
been  similar  to  that  of  a  duodenal  ulcer  bursting  posteriorly  into 
the  retroperitoneal  tissues,  only  in  this  case  it  was  on  the  left 
side. 

A  perigastric  abscess  the  result  of  a  gastric  ulcer  may 
burst  secondarily  in  the  stomach,  as  is  exemplified  in  the 
following  : 

Chronic  Gastric  Ulcer  ;  Abscess  of  Pancreas  bursting 
INTO  Stomach  ;  Vomiting  ;  Impending  Death.  Posterior 
Gastro-enterostomy. 

On  November  i,  1900,  one  of  us  (Mayo  Robson)  was  asked 
by  Dr.  Mercer,  of  Bradford,  to  see  Mr.  R.,  who  was  extremely 
ill  and  supposed  to  be  suffering  from  pancreatic  disease. 

On  arrival  we  found  the  patient,  aged  thirty-five,  extremely 
emaciated,  lying  in  a  typhoid  condition,  vomiting  extremely  offen- 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  169 

sive,  dark-coloured  pus  and  mucus  mixed  with  blood.  He  was 
extremely  feeble  and  had  a  rapid  pulse.  A  tumour  could  be  felt 
above  the  umbilicus,  which  was  tender  to  pressure.  On  distend- 
ing the  stomach  with  COq,  great  pain  was  produced,  and  vomiting 
followed.  The  stomach  was  found  to  be  dilated,  reaching  on  the 
left  side  to  the  level  of  the  umbilicus.  There  had  been  an  elevated 
temperature  for  a  week  or  two,  but  this  had  become  subnormal 
after  the  vomiting  of  pus.  Pain  after  food  and  indigestion  had 
existed  for  some  months,  during  which  time  there  had  been 
steady  loss  of  flesh  ;  but  recently,  especially  during  the  past 
month,  the  wasting  had  been  very  considerable.  There  was  a 
little  sugar  in  the  urine  and  a  trace  of  albumin,  and  the  faeces 
contained  free  fat.  No  medicine  had  done  any  good,  either  in 
relief  of  the  vomiting  or  in  controlling  the  horrible  odour  which 
permeated  the  w^hole  house.  A  diagnosis  of  chronic  gastric  ulcer 
of  the  posterior  wall  of  the  stomach,  with  secondary  ulcerative 
pancreatitis  and  abscess  of  the  pancreas,  was  made,  and  gastro- 
enterostomy proposed  as  the  only  means  likely  to  produce  any 
chance  of  relief,  but  even  that  seemed  almost  hopeless.  He  was 
removed  to  a  surgical  home  by  ambulance,  and  the  stomach  was 
washed  out  carefully  by  my  colleague.  Dr.  Stevens.  As  showing 
the  nature  of  the  stomach  contents,  both  the  attendant  nurses 
were  made  sick  by  the  smell  of  the  material  evacuated  by  the 
tube. 

On  November  18,  after  enveloping  the  patient  in  cotton- wool 
and  subcutaneously  administering  strychnine,  posterior  gastro- 
enterostomy was  performed,  a  bone  bobbin  being  used.  The 
tumour  felt  before  operation  was  found  to  be  formed  by  stomach 
and  pancreas  firmly  fixed  together  towards  the  pyloric  end,  but 
leaving  the  dilated  portion  free  at  the  cardiac  end  of  the  stomach, 
so  that  no  difficulty  was  found  in  doing  a  satisfactory  operation, 
which  was  completed  in  twenty-five  minutes.  Saline  sub- 
cutaneous injections  and  rectal  injections  were  given  and  strych- 
nine was  freely  administered,  but  for  two  days  we  had  a  great 
fight  with  death,  apparently  due  to  poisoning  from  the  foul 
stomach  contents.  Hot  water  was  freely  given  to  induce  vomit- 
ing on  the  second  day,  as  the  patient  could  not  bear  the  stomach- 
tube  being  used.  This  gave  relief,  and  afterwards  progress  to 
recovery  was  uninterrupted.  He  rapidly  gained  strength  and  put 
on  flesh,  returning  home  in  five  weeks  after  operation.  His 
friends,  who  had  despaired  of  his  recovery,  were  astonished  to 
find  him  so  well.  In  April  he  was  in  such  good  health  that  he 
married. 


170  SURGERY  OF  THE  STOMACH 

Treatment. 

The  only  treatment  that  can  be  counted  upon  to  do  good 
in  cases  of  subphrenic  abscess  is  incision,  with  subsequent 
drainage.  There  are  unquestioned  cases  of  abscess  which 
recover  spontaneously,  either  from  the  rupture  of  the  abscess 
cavity  in  one  of  the  directions  already  mentioned  or  from 
gradual  drying  up  of  the  contents.  The  most  exemplary 
instance  of  this  which  we  have  met  with  is  the  following  : 

Symptoms  of  Perforation  of  Gastric  Ulcer,  with  Signs 
OF  Left  Subphrenic  Abscess  and  Peritonitis.  Re- 
covery WITHOUT  Operation. 

Early  in  1900  one  of  us  (Mayo  Robson)  was  asked  to  see  a 
young  lady  of  twenty-one,  with  Dr.  H.  She  had  been  anaemic 
for  several  years,  and  had  for  some  months  shown  signs  of  gastric 
ulcer.  One  evening  during  dinner,  at  which  she  apparently  had 
not  taken  any  food,  she  was  seized  with  acute  pain  in  the  upper 
abdominal  region,  and  became  faint  and  extremely  ill.  She  was 
put  to  bed  immediately,  and  all  food  by  the  mouth  was  stopped, 
as  rupture  of  a  gastric  ulcer' was  suspected. 

When  we  saw  her  later  there  were  well-marked  signs  of  peri- 
tonitis in  the  upper  abdomen,  and  the  recti  were  tense,  especially 
the  left.  The  lower  ribs  were  fixed  and  rigid,  and  there  was  a 
distinct  prominence  beneath  the  left  costal  margin.  From  the 
seventh  rib  downwards  there  was  an  entire  absence  of  breath- 
sounds,  and  percussion  showed  hyper-resonance  with  tension,  as 
if  gas  were  compressed  in  a  hmited  space.  The  temperature  had 
been  raised,  but  was  subsiding,  and  as  the  pulse,  which  had  been 
rapid,  was  quieting  down,  we  decided  to  wait  and  watch  the  case, 
feeding  by  the  bowel  and  keeping  the  stomach  free  from  food. 
Recovery  was  gradual,  but  complete,  and  we  hear  that  the  patient 
is  now  well. 

According  to  Lang,  who  has  collected  176  cases  from 
surgical  literature,  after  operation  the  percentage  of  re- 
coveries is  47*9  per  cent.,  and  of  the  recoveries  without 
operation  12*3  per  cent.  Beck  found  6  spontaneous  re- 
coveries in  146  cases.  The  incision  should  be  made,  as  a 
rule,  over  the  most  prominent  point  of  the  abscess.  This 
may  be  in  the  abdominal  wall,  below  the  costal  margin  in 
front,  or  behind  in  the  lumbar  region,  or  in  the  thoracic  wall. 

The  incision  is  carefull}^  made  into  the  abscess  cavity,  the 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  171 

contents  emptied,  and  the  cavity  flushed  with  sterile  solu- 
tion, or,  and  this  is  better,  carefully  sponged  until  as  clean 
as  possible.  Flushing  may  lead  to  rupture  of  protective 
adhesions,  and  if  adopted  should  be  carefully  supervised. 
If,  after  so  cleansing  the  cavity,  the  ulcer  which  has  per- 
forated can  be  recognised,  and  is  easily  accessible,  it  may  be 
stitched  up.  Drainage  by  means  of  large  tubes  with  gauze 
wicks  is  adopted. 

When  the  thoracic  wall  has  to  be  incised,  the  pleural 
cavity  is  opened  by  resection  of  one  or  more  ribs.  The 
parietal  and  diaphragmatic  layers  of  the  pleura  are  then 
stitched  together  and  the  diaphragm  is  incised.  Drainage 
is  adopted  in  the  manner  above  described. 


Subphrenic    Abscess    discharging    through    Lung.     Drain- 
age ;  Recovery. 

Miss  Isabel  P.,  aged  twenty-four,  was  sent  to  Mayo  Robson 
on  June  i,  igoo,  by  Dr.  Densham,  of  Stockton,  with  the  history 
of  three  years'  indigestion  and  vomiting,  ending  in  perforation  of 
gastric  ulcer  and  peritonitis  in  November,  1899.  She  was  ex- 
tremely ill  and  for  many  weeks  in  a  dangerous  state,  but  gradually 
improved.  A  month  after  the  perforation  there  were  signs  of 
suppuration  with  some  dulness  at  the  base  of  the  left  chest,  and 
two  months  after  the  perforation  an  abscess  burst  through  the  left 
lung  and  a  large  quantity  of  offensive  pus  was  coughed  up,  and  con- 
tinued to  be  coughed  up,  until  she  reached  the  Leeds  Infirmary, 
where  the  purulent  expectorations  measured  about  half  a  pint 
daily.  She  was  then  extremely  feeble  and  suffering  from  a  hectic 
temperature.  There  was  dulness  over  the  lower  part  of  the  left 
lung.  On  examining  the  offensive  material  expectorated,  muscu- 
lar fibres  were  found  in  it,  but  no  elastic  tissue,  thus  showing  the 
source  of  the  pus. 

An  exploring  needle  used  in  the  ninth  left  intercostal  space 
found  pus.  A  portion  of  the  ninth  rib  was  therefore  dissected, 
and  an  incision  made  through  the  thoracic  wall  and  diaphragm 
into  the  abscess  cavity,  which  was  freely  drained.  Recovery  was 
rapid,  and  the  foul  expectoration  ceased  at  once. 

The  opening  leading  from  the  stomach  to  the  abscess  closed 
spontaneously,  and  the  tube  was  left  out  in  about  a  month,  after 
which  the  wound  closed.  She  was  sent  to  a  convalescent  home, 
and  returned  home  in  three  months  well. 


172  SURGERY  OF  THE  STOMACH 

The   following   are  the   recorded  results  of  perforation  of 
the  stomach  the  result  of  ulceration  : 

1.  Acute  Perforation. — Acute  septic  peritonitis;  secondarily, 
perigastric  or  subphrenic  abscess. 

2.  Chronic  Perforation.  —  The  ulcer  may  be  supported  on 
the  outer  side  by  adhesions  to — 

Omentum, 

Abdominal  wall,  leading  to  external  gastric  fistula, 
Diaphragm, 

Solid  viscera,  liver,  spleen,  pancreas,  lymphatic  glands. 
The  ulcer  may  perforate  into  the  lesser  sac,  the  foramen 
of  Winslow  being  closed. 

The  ulcer  may  perforate,  a  perigastric  abscess  forming  and 
bursting  into — 

Pleura, 
Pericardium, 
Heart, 
Bronchus, 
Mediastinum  ; 
or  into  hollow  viscera,  forming  internal  gastric  fistula : 
Intestine,  large  or  small, 
Stomach, 
Gall-bladder, 
Common  bile-duct, 
Pancreatic  duct ; 
or  into  peritoneum  or  subperitoneal  tissue,  causing  emphy- 
sema of  subcutaneous  or  subperitoneal  tissue,  or  leading  to 
the  occurrence  of  gas  in  the  veins  and  arteries  (Jiirgensen). 

(The  gas  found  in  general  emphysema  is  said  to  consist 
chiefly  of  hydrogen,  and  to  burn  with  a  blue  flame.) 


CHAPTER  XI 
THE  COMPLICATIONS  OF  GASTRIC  ULCER  {continued) 

Hour-glass  Stomach. 

By  '  hour-glass '  stomach  is  understood  that  condition  of  the 
stomach  in  which  the  viscus  is  divided  into  two  cavities. 
The  cavities  are  generally  of  unequal  size.  The  terms 
'hour-glass  contraction  of  the  stomach,'  'double  stomach,' 
and  '  bilocular  stomach '  have  been  adopted  by  various 
authors. 

Hour-glass  stomach  may  be  described  as  congenital  and 
acquired. 

Congenital  hour-glass  stomach  is  commonly  asserted  to 
be  the  more  frequent  variety.  Thus  Fenwick  writes  :  '  In 
about  45  per  cent,  of  the  cases  which  have  been  recorded 
neither  ulcer  nor  scar  could  be  detected  in  the  stomach, 
while  in  the  great  majority  of  the  cases  where  an  ulcer  was 
present  it  was  obviously  of  more  recent  formation  than  the 
stricture.'  And  again:  'That  the  deformity  is  a  rare  result 
of  ulceration  is  proved  by  the  fact  that  only  one  case  of  the 
kind  is  mentioned  in  the  records  of  the  London  Hospital  for 
forty  years,  whereas  several  instances  of  the  congenital  form 
of  the  disease  were  encountered  during  the  same  period  of 
time.'  Similar  statements  have  been  made  by  Carrington, 
Roger  Williams,  Hirsch,  and,  in  fact,  every  writer  who  has 
dealt  with  the  subject. 

We  consider  that  the  evidence  of  the  existence  of  hour- 
glass stomach  as  a  congenital  deformity  is  insufficient  to 
be  convincing.  It  cannot  be  denied  that  congenital  cases 
may  exist,  for  as  a  fact  they  are  not  improbable  when  we 


174  SURGERY  OF  THE  STOMACH 

contemplate  the  circumstances  in  congenital  stenosis  of  the 
pylorus ;  but  we  are  sceptical  that  any  of  the  recorded  cases 
of  congenital  deformity  are  in  reality  of  such  an  origin.  It 
is  a  noteworthy  fact  that  in  many  of  the  so-called  congenital 
cases,  if  not  in  all,  ulceration  was  present  in  some  part  of 
the  stomach.  This  is  true  of  Carrington's  cases,  of  Hudson's, 
Saundby's,  Williams's,  and  Hirsch's.  In  Watson's  iirst  case 
it  is  said  that  the  mucous  membrane  at  the  point  of  constric- 
tion and  on  each  side  of  it  '  is  thrown  into  abnormall}-  heavy 
ridges,'  which  implies  that  a  process  of  narrowing  from  a 
larsfer  bulk  has  here  occurred.     In  certain  of  the  museum 


Fig.  40. — Hour-glass   Stomach  ;    probably   congenital   with    Growth 
ROUND  Cardiac  Orifice. 

(No.  2,416,  Royal  College  of  Surgeons'  Museum.) 

specimens  labelled  '  congenital '  it  is  quite  clear  that  no 
adequate  examination  of  the  specimen  has  ever  been  made. 
Indeed,  such  an  examination  necessitates  a  so  free  handling 
of  the  specimen  as  to  spoil  it  entirely  for  decorative  purposes. 
The  simple  aspect  of  a  pathological  constriction  can  be  most 
deceptive.  One  of  the  cases  related  below  was  an  exemplary 
instance  of  this.  The  isthmus  uniting  the  cardiac  and  pyloric 
cavities  was  barely  the  size  of  one's  little  finger ;  it  was  per- 
fectly soft,  smooth,  and  everywhere  supple.  There  was  no 
trace  of  any  thickening  or  puckering  of  the  surface.  On 
invaginating  a  finger  into  the  cavity  on  each  side  of  the 
narrowing,   no  orifice   could    be    felt    leading    from   the   one 


THE  COMPLICATIONS  OF  GASTRIC  ULCER 


'75 


to  the  other.  To  all  appearance,  no  pathological  process 
had  ever  existed  there.  On  slitting  the  stricture  up,  as  a 
preliminary  to  performing  gastroplasty,  the  following  condi- 
tion was  found :  The  passage  was  equal  in  diameter  to  a 
No.  4  or  5  catheter,  most  of  its  circumference  was  natural  in 
appearance,  but  at  the  upper  and  anterior  part  was  a  small 
dead  white  area,  clearly  cicatricial,  and  from  near  this  there 
ran,   on    the    pyloric  side,  vertically   down   to  the  opposing 


Fig.  4[. — Cancer  of  Anterior  Wall  of  the  Stomach  producing  Hour- 
glass Contraction. 
Man,  aged  sixty,  with  four  years'  history  of  vomiting,  and  other  signs  of  ulcer. 

This  is  an  example  of  '  ulcus  carcinomatosum.'     (No.  2,4086,  Royal  College 

of  Surgeons'  Museum.) 


mucous  surface,  a  column  clad  completely  in  mucous  mem- 
brane, and  ^  inch  in  diameter.  The  column  was  removed 
between  two  ligatures,  and  it  was  then  found  to  be  built  up 
of  dense  fibrous  tissue.  There  was,  in  fact,  a  '  bridle  stric- 
ture'  in  the  stomach.  That  it  was  pathological  admits  of  no 
question,  yet  nothing  short  of  a  division  of  the  stricture  could 
have  revealed  its  inflammatory  origin.    There  can  be  no  doubt 


176  SURGERY  OF  THE  STOMACH 

that,  if  the  whole  stomach  had  been  obtained  from  a  post- 
mortem examination,  the  specimen  would  have  been  pro- 
claimed an  admirable  example  of  congenital  hour-glass 
stomach. 

Hochenegg  on  a  similar  case  performed  the  operation  of 
gastro-gastrostomy.  No  careful  examination  of  the  narrow 
stricture  was  made,  but  the  case  is  quoted  as  an  example  of 
'  congenital '  deformity.  Such  a  case  is  quite  inadmissible. 
Do}'en's  case,  referred  to  in  the  list,  is  christened  '  con- 
genital." At  the  point  of  narrowing  there  was  an  ulcer 
adherent  to  the  anterior  abdominal  wall.  On  separating 
the  adhesions,  a  gastric  fistula  was  exposed,  showing  un- 
mistakably that  a  localized  perforation  of  the  ulcer,  with 
anchoring,  was  responsible  for  the  warping  of  the  stomach. 

Williams  {Joiirn.  Anat.  and  Physiol.,  1883)  describes  ten 
cases  of  '  congenital  contraction  of  the  stomach.'  The 
account  of  one  of  the  cases  is  based  on  the  examination 
of  a  wax  model,  of  another  on  the  inspection  of  an  'inflated 
dried '  specimen,  and  a  third  on  the  appearance  of  a  '  dried 
stuffed '  specimen.  It  is  doubtful  whether  one  of  the 
examples  can  be  accepted  as  an  'hour-glass'  stomach. 
In  all  the  rest  pathological  conditions,  ulceration,  puckering, 
thickening,  adhesion  to  pancreas,  were  present.  It  is  im- 
probable that  any  of  the  stomachs  was  the  seat  of  a 
congenital  deformity.  The  same  criticism  applies  to  Car- 
rington's  cases  and  to  Maier's. 

The  facts  that  pathological  changes  producing  marked 
changes  in  the  contour  of  the  stomach  may  be  incon- 
spicuous, that  ulceration  in  association  with  '  congenital ' 
deformity  is  not  infrequent,  and  that  in  many  of  the  examples 
no  purposeful  examination  of  the  specimen  has  been  made, 
warrant  us  in  saying  that  congenital  hour-glass  stomach 
is  certainly  rare,  and  not  improbably  mythical. 

In  20  examples  of  this  supposed  variety  collected  by 
Watson,  the  stricture  was  situate  in  the  middle  in  7,  at 
the  junction  of  the  upper  and  middle  thirds  in  3,  at  the 
junction  of  the  lower  and  middle  thirds  in  4,  and  was  not 
noted  in  6. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  ijy 


Acquired  Hour-glass  Stomach. 

Acquired  hour-glass  stomach  ma}-  be  caused  by — 

1.  Perigastric  adhesions. 

2.  Ulcer  with  local  perforation  and  anchoring  to  the 
anterior  abdominal  wall. 

3.  Circular  ulcer,  with  subsequent  cicatricial  contraction 
and  induration, 

4.  Cancer. 

1.  Perigastric  Adhesions. — These  may  be  the  result  of  many 
causes,  among  them  being  perforation  of  a  gastric  ulcer. 
The  adhesions  chiefly  concerned  in  producing  the  condition 
may  be  a  thick  cord  running  downwards  from  the  liver,  and 
sharply  pressing  into  the  anterior  wall  of  the  stomach.  In 
one  of  Mayo  Robson's  cases  such  an  adhesion  caused  the 
cardiac  end  of  an  hour-glass  stomach  to  be  itself  divided 
into  two,  thus  forming  a  '  trifid  stomach.' 

2.  Ulcer  with  Local  Perforation  and  Anchoring  of  the  Stomach 
to  the  Anterior  Abdominal  Wall. — In  this  form  a  chronic  ulcer 
of  the  anterior  wall  of  the  stomach  makes  its  way  in  languid 
fashion  through  the  coats  of  the  organ.  As  it  nears  the 
serous  coat  adhesions  are  formed,  binding  it  to  the  parietal 
peritoneum,  which  solders  the  base  and  prevents  a  general 
leakage.  The  stomach  being  then  firmly  anchored  at  this 
one  point,  a  sagging  of  the  cavity  on  each  side,  but  chiefly  in 
the  cardiac  side,  occurs,  and  this,  with  the  cicatricial  con- 
traction occurring  in  the  ulcer,  results  in  an  hour-glass 
stomach.     Excellent  examples  of  this  are  referred  to  below. 

Similar  cases  are  recorded  by  Steffan  and  Finney. 
Cases  of  general  perforation  into  the  peritoneal  cavity  are 
recorded  by  Siew^ers  and  W.  H.  Brown. 

3.  Circular  Ulcer,  with  Subsequent  Cicatricial  Contraction  and 
Induration. — Such  an  ulcer  extends  transversely  to  the  long 
axis  of  the  stomach,  and  in  its  contraction  while  healing  must 
inevitably  cause  a  high  degree  of  narrowing  (see  Fig.  32). 
The  simple  round  ulcer  is  also  fully  competent  to  produce  a 
stricture,  though  probably  not  wdth  the  sanie  completeness 
as  the  former.     The  conditions  found  in  some  of  our  cases 

12 


178  SURGERY  OF  THE  STOMACH 

suggest  very  forcibly  the  likelihood  of  the  ulcer  having  per- 
forated into  the  general  peritoneal  cavity. 

The  stricture  may  be  placed  at  any  part  of  the  stomach ;  it 
is  generally  near  to  the  middle,  or  rather  to  the  pyloric  side 
of  the  middle.  The  calibre  of  the  orifice  may  vary  from  that 
of  a  No.  4  or  No.  5  catheter  to  that  sufficient  to  allow  of  the 
passage  of  three  fingers.  The  greater  curvature  is  generally 
puckered  up  towards  the  lesser,  but  the  reverse  is  recorded  in 
one  case  by  Schwarz. 


Fig.  42. — Cancer  of  the  Cardiac  End  of  the  Stomach  causing  the 
Fundus  to  be  partially  shut  off,  so  as  to  form  a  large  Pouch. 
(Modification  of  Hour-glass  Stomach.) 

From  a  woman  of  fifty,  who  had  had  symptoms  for  three  years.     '  Ulcus  car- 

cinomatosum. ' 

4.  Cancer. — Cancer  of  the  stomach  is  a  not  infrequent  cause 
of  hour-glass  stomach.  In  some  of  the  specimens  the  cancer 
has  clearly  been  implanted  upon  a  chronic  ulcer  ('  ulcus  car- 
■cinomatosum ').  In  others,  the  cancer,  originating  in  a  localized 
area  of  the  stomach,  and  there  producing  the  constriction  of 
the  hour-glass,  has  in  its  later  growth  involved  the  greater 
part,  or  even  the  whole,  of  the  stomach.  The  stomach  then 
is  thickened  in  all  its  coats  by  a  diffuse  growth,  and  the 
condition  described  as  '  leather-bottle  '  stomach  results. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  179 

Symptoms. 

The  symptoms  of  hour-glass  stomach  are  oftenest  those 
of  dilated  stomach  supervening  upon  chronic  ulcer  of  the 
stomach.  In  most  of  the  cases  recorded  a  diagnosis  of 
'  dilated  stomach  '  has  been  made,  and  in  those  dealt  with 
surgically  operative  interference  has  been  undertaken  for  the 
relief  of  supposed  pyloric  stenosis.  In  certain  cases,  however, 
the  symptoms  and  signs  are  clear  and  pointedly  characteristic. 
In  four  of  our  cases  a  confident  diagnosis  was  made  thereon. 

Two  of  the  most  helpful  signs  were  pointed  out  by  Wolfler. 
They  are  : 

1.  These  phenomena  were  observed  upon  washing  out  the 
stomach.  The  fluid  introduced  into  the  stomach  seemed  to 
disappear  altogether,  '  as  though  it  had  flowed  through  a 
large  hole,'  and  is  not  returned  through  the  tube.  In  such  a 
circumstance  the  fluid  passes,  it  is  obvious,  from  the  one 
compartment  to  the  other. 

2.  It  was  further  noticed  that  when  the  stomach  was 
washed  out  until  the  lotion  returned  clear,  a  sudden,  unlooked- 
for  gush  of  foul,  or  even  putrid,  fluid  occurred ;  or  if,  after 
gentle  lavage  until  the  stomach  seemed  clean,  an  interval  of 
a  few  minutes  was  allowed  to  elapse,  and  the  tube  again 
passed,  foul  or  dirty  fluid  at  once  returned.  This  is  due, 
doubtless,  to  the  reflux  of  the  contents  of  the  pyloric  cavity 
through  the  stricture. 

Jaworski  (Wien.  Klin.  Woch.,  i8g8)  noticed  in  one  instance 
that,  after  apparently  emptying  the  stomach  by  passing  the 
tube,  a  splashing  sound  could  still  be  obtained  by  palpation 
over  the  gastric  area.  The  pyloric  cavity,  which  is  not 
drained  by  the  stomach-tube,  causes  this  suggestion  of  dilated 
stomach.  The  condition  has  been  appropriately  described  as 
'  paradoxical  dilatation.' 

Eiselsberg  remarked  in  one  of  his  cases,  that  upon  injecting 
a  quantity  of  fluid  into  the  stomach  there  was  a  bulging  and 
distension  of  the  left  side  of  the  epigastrium  ;  after  a  few 
moments  this  gradually  sank  and  subsided,  and  simul- 
taneously a  swelling  of  the  right  side  of  the  epigastrium 
slowly  developed. 

12 — 3 


I  So  SURGERY  OF  THE  STOMACH 

A  sign  to  which  Eiselsberg  also  called  attention  in  this 
case  was  well  exhibited  in  two  of  our  cases.  On  distending 
the  stomach  with  COo,  the  bubbling  arid  gushing  of  fluid 
through  a  narrow  chink  could  be  heard  with  the  stethoscope, 
an  observation  that  was  repeated  in  Watson's  case.  If  the 
area  of  gastric  resonance  be  marked  out  before  and  after 
distension,  a  marked  increase,  even  to  doubling,  is  noticed  in 
the  resonance  of  the  cardiac  complement,  while  the  pyloric 
complement  may  seem  to  mimic  the  appearance  of  a  dilated 
stomach.  Investigation  in  this  manner  would  have  revealed 
this  sign  very  clearly  in  Pollard's  case  and  in  Childe's  case, 
recorded  in  the  list.  There  can  be  no  risk  in  distending  the 
stomach  with  COo,  and  therefore  this  method  should  be 
adopted  in  all  doubtful  cases.  It  seems  not  unlikely  that 
the  sign  will  be  most  helpful  in  making  an  accurate  diagnosis. 
In  two  cases,  seen  by  Schmidt-Monard  and  Eichhorst,  a 
distinct  sulcus  separating  two  dilated  cavities  was  seen  on 
inflation  with  COo.  This  appearance  was  observed  in  a 
patient  seen  in  private  at  separate  consultations  by  both  of 
us.  In  slighter  cases  of  constriction,  a  notch  may  be  recog- 
nised in  the  lower  margin  of  the  stomach. 

The  symptoms  resulting  from  a  narrowing  in  the  stomach 
will  naturally  depend  upon  the  part  of  the  viscus  aftected. 
If  the  contraction  be  near  the  pylorus,  the  cardiac  pouch 
will  distend  to  almost  any  capacity,  and  the  clinical  picture 
will  be  that  of  dilatation  of  the  stomach.  If  the  stricture  be 
placed  but  a  little  wa}-  from  the  cardiac,  the  symptoms  will 
suggest  oesophageal  obstruction.  The  differential  diagnosis 
can,  however,  be  achieved  by  noting  the  distance  which  the 
oesophageal  bougie  passes.  In  one  case,  seen  with  Dr.  Sykes, 
of  Cleckheaton,  a  correct  diagnosis  was  made,  and  a  seem- 
ingly accurate  estimate  of  the  capacity  of  the  cardiac  com- 
plement made  by  observing  the  following  symptoms  :  When 
the  patient  took  a  tablespoonful  of  milk  he  retained  it ;  if  an 
ounce  or  two  were  drunk  at  a  gulp,  the  greater  part  was 
returned.  The  stomach-tube  passed  i8  inches  without  diffi- 
culty. On  attempting  to  wash  the  stomach  out,  i  ounce  or 
a  little  more  of  fluid  passed  in,  but  no  more.  We  adminis- 
tered a  seidlitz  powder  in  separate  halves.     The  first  half 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  i8i 

was  retained ;  on  administering  the  second,  the  patient  was 
overwhelmed  by  a  gush  of  foam,  which  burst  from  his  mouth 
and  nostrils.  The  diagnosis  of  hour-glass  stomach  with  a 
smaller  cardiac  and  a  larger  pyloric  segment  was  made.  At 
the  operation  this  condition  was  found ;  it  was  the  result  of 
malignant  disease,  which  had  already  caused  secondary 
deposits  in  the  parietal  peritoneum  and  ascites. 


Fig.  43.— Types  of  Hour-glass  Stomach, 
I,  Constriction  near  the  cardia  (simulates  oesophageal  obstruction)  :  2,  cardiac 
complement  hidden  by  adhesion  (thorough  examination  of  the  whole  stomach 
is  necessary-)  ;  3,  constriction  with  much  induration  ;  4,  a  narrow  channel 
connects  the  two  pouches  ;  5,  constriction  near  the  pylorus  (simulates  pyloric 
obstruction) ;  6,  hour-glass  stomach  (the  cardiac  complement  subdivided  by 
an  adhesion),  '  trifid  stomach.' 


The  characteristic  signs,  then,  are  : 

1.  Disappearance  of  fluid  introduced  through  the  stomach 
tube,  '  as  though  it  had  flowed  through  a  hole  '  (Wolfler). 

2.  After  cleansing  of  the  stomach  by  lavage,  a  sudden  gush 
of  putrid,  sour,  ill-digested  food,  etc.  (Wolfler). 

3.  'Paradoxical  dilatation';    succussion  splash  in.  pyloric 
cavity  after  siphonage  of  the  cardiac  (Jaworski). 


i82  SURGERY  OF  THE  STOMACH 

4.  Distension  of  cardiac  loculus,  its  gradual  subsidence, 
and  concomitantly  the  distension  of  the  p}-loric  loculus 
(Eiselsberg). 

5.  During  this  period  a  gurgling,  forcing  sound  heard  over 
or  near  the  middle  of  the  stomach  (Eiselsberg). 

6.  On  distension  with  COo,  a  large  increase,  even  to  a 
doubling,  in  the  thoracic  area,  tympanitic  on  percussion,  and 
a  slight  distension,  clearly  demarcated,  of  the  pyloric  loculus. 

7.  Rarely  a  sulcus  may  be  seen  on  inflating  with  CO2. 


Treatment. 

The  following  operations  have  been  practised  in  cases  of 
hour-glass  stomach: 

1.  Gastroplasty  with  or  without  resection  of  the  ulcer. 

2.  Gastro-gastrostom}^,  or  gastro-anastomosis. 

3.  Gastro-enterostomy. 

4.  Partial  gastrectomy. 

Frequentl}-,  owing  to  the  existence  of  adhesions,  gastrolysis 
has  to  be  performed  in  addition  to  the  operations  mentioned. 

The  choice  of  an  operation  will  be  determined  by  the 
conditions  found  at  the  operation.  It  is  essential  that  a 
careful  and  complete  examination  of  the  whole  stomach  be 
made  before  the  curative  procedure  is  adopted.  For  in  some 
of  the  cases  related  below  it  will  be  noticed  that  the  lack  of 
adequate  and  precise  knowledge  has  led  to  futile  measures 
and  fatal  results. 

If  the  constriction  be  near  the  middle  of  the  stomach,  if 
there  be  little  induration  and  no  active  ulceration,  and  if  the 
pylorus  be  free,  a  gastroplasty  will  prove  successful. 

If  the  constriction  be  in  any  part  of  the  middle  third  or 
half  of  the  stomach,  if  the  pouches  on  each  side  are  '  sagging  ' 
and  free  from  adhesion,  and  if  the  pylorus  is  free,  a  gastro- 
gastrostomy  will  suffice  to  effect  a  cure. 

If,  however,  the  stomach  narrowing  be  associated  with 
pyloric  stenosis,  the  existence  of  which  must  be  suspected  if 
the  pyloric  segment  is  dilated  also,  no  single  operation  will 
suffice.  A  gastroplasty  and  a  pyloroplasty,  or  a  gastroplasty 
and  a  posterior  gastro-jejunostom}-,  must  both  be  performed. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  183 

It  is  possible,  in  some  cases,  such  as  that  of  Schwarz, 
where  the  lesser  curvature  is  dragged  down  to  the  greater, 
that  the  incision  dividing  the  constriction  to  the  stomach 
might  be  utilized  for  the  purposes  of  an  anterior  gastro- 
jejunostomy. 

If  on  separating  parietal  adhesions  a  gastric  fistula  be 
found,  as  in  Doyen's  case  and  in  two  of  ours,  the  ulcer  may 


Fig.  44. — Stomach    showing    two    Perforating    Ulcers:    one  ox  the 
Anterior,  one  on  the  Posterior,  Surface. 


be  excised,  or  its  edges  refreshed,  and  a  gastroplasty  be  per- 
formed. 

If  the  constriction  be  due  to  new  growth,  a  partial  or 
complete  gastrectomy  may  be  performed.  If  these  prove  not 
feasible,  a  palliative  jejunostomy  may  be  necessary. 

Various  operators  have  expressed  individual  preference  for 
certain  methods.  Thus,  Eiselsberg  prefers  gastro^enteros- 
tomy.       He  has  performed  operations  upon  eight  patients ; 


1 84  SURGERY  OF  THE  STOMACH 

three  of  the  patients  died  as  a  result  of  the  operation, 
and  of  the  five  survivors  one  suffered  from  a  recurrence 
of  the  S3'mptoms  at  the  end  of  nine  months.  Eiselsberg 
objects  to  gastroplasty  that  recurrence  of  the  stenosis  is 
probable.  The  same  objection  has  been  brought  by  Berg 
and  others  against  pyloroplasty.  The  probabilit}'  is  that 
while  the  process  of  ulceration  is  still  active,  or  induration 
or  adhesions  are  present,  it  is  unwise  to  perform  a  gastro- 
or  pyloro-plast}-. 

It  is  especially  important  to  observe  the  condition  of  the 
pyloric  portion  of  the  stomach.  If  the  isthmus  be  a  narrow 
one,  the  pyloric  segment  should  be  small  and  empty.  If  the 
pyloric  cavity  be  dilated,  as  is  expressly  noted  in  Jaboulay's 
case  and  in  Watson  Cheyne's,  there  is  a  strong  presumption 
in  favour  of  the  existence  of  a  pyloric  narrowing.  If  such 
narrowing  be  present  and  a  gastroplasty  alone  be  performed, 
the  operation,  though  '  successful '  so  far  as  recovery  is  con- 
cerned, cannot  be  expected  to  relieve  the  patient  of  all  dis- 
abilities, and  a  second  operation  may  be  imperative. 

1.  Gastroplasty  is  an  adaptation  to  the  body  of  the  stomach 
of  Heineke's  operation  for  pyloric  stenosis.  It  was  performed 
by  Bardeleben  in  1889,  Kruckenberg  in  1892,  and  later  by 
Zeller  and  Doyen  and  others. 

A  transverse  incision,  4  inches  in  length  at  least,  is  made, 
dividing  the  stricture.  The  incision  is  then  stitched  up 
vertically.  Two  continuous  layers  of  sutures  are  introduced 
— one  for  the  mucous  membrane  only,  or  all  the  coats,  and 
the  other  for  the  serous  or  subserous  coats  alone. 

One  of  us  (Mayo  Robson)  employs  a  large  bone  bobbin, 
over  which  the  sutures  are  applied. 

2.  Gastro-gastrostomy,  or  gastro-anastomosis,  was  first  per- 
formed by  Wolfler  in  1894.  The  incisions  made  into  the 
dependent  pouches  on  each  side  of  the  constriction  were 
vertical,  and  7  centimetres  in  length.  An  adequate  anasto- 
mosis between  the  two  halves  w^as  thus  made. 

Sedgwick  Watson,  in  1895,  successfully  performed  gastro- 
anastomosis  in  a  different  manner.  The  incisions  in  the  two 
segments  of  the  stomach  were  transverse.  The  pyloric  portion 
of  the  viscus  was  folded  over  the  cardiac,  with  the  constricting 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  185 

isthmus  as  a  hinge,  and  the  two  stitched  together  with  an 
ehiptical  Hne  of  sutures  before  being  opened.  The  anasto- 
mosis was  then  made  by  incising  the  wall  of  the  pyloric  com- 
partment, which  now  lay  anterior  and  through  the  opposite 
surface,  making  the  anastomosis.  This  method  is  unneces- 
sarily cumbersome,  and  possesses  no  potential  advantages 
over  Wolfler's  method. 

3.  Grastro-enterostomy  is  not  generally  applicable,  for  if  the 
pyloric  pouch  be  united  to  the  jejunum,  as  in  Pollard's  case 
and  in  Childe's,  the  operation  will  avail  nothing  ;  for  the 
disability  is  due  to  the  fact  that  food  cannot  enter  the  pyloric 
portion  of  the  stomach.  If  the  cardiac  complement  be  united 
to  the  intestine,  the  pyloric  pouch  is  undrained,  and  symptoms 
will  persist  and  necessitate  a  second  operation,  as  in  Tufiier's 
case.  Weir  and  Foote  {Medical  News,  1896)  advise  that  a 
double  anastomosis  between  both  pouches  and  the  jejunum 
be  made  at  the  same  operation,  a  method  that  would  probably 
prove  satisfactory. 

4.  Partial  Gastrectomy. — In  cases  of  cancer  always,  and  in 
certain  cases  of  simple  disease,  a  partial  gastrectomy  may  be 
the  operation  of  choice.  In  cancer  a  wide  excision  should 
be  made ;  in  simple  disease  a  removal  of  the  constriction 
will  suffice.     In  both  an  end-to-end  suture  is  desirable. 

A  further  description  of  these  procedures  will  be  found  in 
the  chapter  on  Operations. 

The  following  is  a  complete  list  of  all  recorded  cases  : 

Case  i  :  Bardelebex,  i88g. — Hour-glass  stomach.  Gastro- 
plasty. Recovery  and  relief.  (Klemperer,  Berliner  Klinische 
Wochenscrift,  1889.) 

Case  2  :  Kruckenberg,  1892. — Thickened  scar  on  the  anterior 
surface.  Gastroplasty  with  excision  of  ulcer.  Recovery  with 
complete  relief.  (Schmidt-Monard,  Milnchenev  Medicinische  Wochen- 
schrift,  1893,  No.  19.) 

Case  3:  Zeller,  1893. — Hour-glass  stomach,  the  result  of 
healed  ulcer ;  cicatrix.  Resection  of  cicatrix  of  healed  ulcer. 
Death  from  septic  peritonitis,  result  of  perforation  of  another 
ulcer.     {Centralhlatt  filv  Chinirgie,  1894.) 

Case  4  :  Doyen,  1893. — Constriction  at  middle  of  stomach,  due 
to  ulcer  adherent  to  the  anterior  abdominal  wall.  On  separating 
adhesions  a  gastric  fistula  was  found.      Scraping  of  ulcer  and 


1 86  SURGERY  OF  THE  STOMACH 

inversion  ;  gastroplasty.  (This  case  is  called  congenital.)  Re- 
covery. ('  Traitement  Chirurgical  des  Affections  de  I'Estomac,' 
Paris,  1895,  P-  308.) 

Case  5  :  Wolfler,  1894. — Stomach  constricted  into  two  equal 
portions  by  scar  of  ulcer.  Gastro-gastrostomy.  Recovery ;  at 
the  end  of  three  months  quite  well,  and  had  gained  9  kilogrammes 
in  weight.     {Beitrage  zuv  Klinischcn  Chinirgie,  1895,  No.  13.) 

Case  6  :  Eiselsberg,  1894. — Cicatrix  of  old  ulcer.  Gastro- 
gastrostomy.  Death  ;  sutures  introduced  into  indurated  area  had 
cut  through.  Septic  peritonitis.  {Avchiv  fiiv  Klinische  Chirnrgie, 
Band  1.) 

Case  7  :  Watson,  1895. — Constriction  at  junction  of  middle 
and  lower  thirds,  the  result  of  old  ulcer.  Gastro-gastrostomy. 
Recovery ;  complete  relief ;  gained  42  pounds  in  six  months. 
(Boston  Medical  and  Surgical  Journal,  1896.) 

Case  8  :  Lauenstein,  1895. — Constriction  due  to  cicatrix,  from 
which  adhesions  ran  to  liver.  Gastro-gastrostomy.  Recovery  ; 
in  three  months  gained  35  pounds.  {M nnchener  M edicinische  Wochen- 
schrift,  1896,  No.  43.) 

Case  9:  Langenbuch,  1896. — Hour-glass  stomach.  Gastro- 
plasty. Recovery  without  relief.  {Berliner  Klinische  Wochen- 
schrift,  1896  ;  These  de  Lyons,  1896.) 

Case  10  :  Van  Noorden,  i8g6. — Perforation  of  the  stomach 
by  ulcer.  Establishment  of  fistula.  Death  on  fifty-sixth  day, 
[Milnchener  Medicinische  Wochenschrift,  1896.) 

Case  ii  :  Hofmeister,  1896. — Ulcer  and  cicatrix.  Excision 
of  ulcers.  Gastroplasty.  Recovery.  (Beitrage  zur  Klinischen 
Chirnrgie,  1896.) 

Case  12  :  Schwarz,  1896. — Constriction  near  middle,  due  to 
adhesions  extending  to  diaphragm,  liver,  etc.  The  lesser  curva- 
ture was  drawn  down  to  greater.  Gastro-gastrostomy  ;  gastro- 
lysis  at  second  operation.  Symptoms  not  improved  until  after 
second  operation.     (Wiener  Klinische  Wochenschrift,  June,  1896.) 

Case  13  :  Eiselsberg,  1896. — Large  ulcer  on  greater  curva- 
ture, near  fundus  ;  adhesions  to  anterior  abdominal  wall.  Gastro- 
plasty. Recovery ;  return  of  symptoms  after  nine  months. 
(Archiv  fi'ir  Klinische  Chirnrgie,  1899.) 

Case  14:  Jaboulay,  1896. — Constriction  very  narrow  in  pyloric 
third  of  stomach.  Both  cavities  dilated.  Cicatrix  near  lesser 
curvature  ;  adhesions  to  the  left  lobe  of  the  liver.  Gastroplasty. 
Recovery  ;  relief  of  symptoms.  (Archives  Provinciates  de  Chirnrgie, 
1896.) 

Case  15  :  Tuffier,  1897. — Hour-glass  stomach  ;  both  cavities 
dilated.  Gastro-enterostomy  between  cardiac  pouch  and  intes- 
tine ;  symptoms  not  wholly  relieved.     At  a  second  operation  a 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  187 

gastro-enterostomy  between  pyloric  pouch  and  intestine.  Re- 
covery from  both  operations  ;  complete  relief  after  the  second. 
{Bulletin  et  Memoive  de  la  Societe  de  Chirurgie,  1897.) 

Case  16:  Watson  Cheyne,  1897. — Constriction  permitting 
passage  of  a  crow-quill  only  in  middle  of  the  stomach.  Both 
parts  of  the  stomach  dilated.  Gastroplasty.  Recovery.  [Lancet, 
March  19,  1898,  p.  785.) 

Case  17  :  Eiselsberg,  1898. — Constriction  admitting  little 
finger  in  pyloric  third  of  organ  ;  adhesions  to  liver  and  pancreas  ; 
perigastric  abscess.  Gastroplasty.  Death  in  ten  hours.  [AvcJiiv 
fur  Klinisch&  Chimrgie,  Band  lix.) 

Case  18  :  Eiselsberg,  1898. — Constriction  in  middle  of  the 
stomach  ;  adhesions  to  posterior  abdominal  wall  and  liver,  and 
erosion  of  pancreas  by  open  ulcer.  Gastroplasty  ;  jejunostomy. 
Death  in  twelve  hours.     [Archiv  filr  Klinische  Chimrgie,  Band  lix.) 

Case  ig  :  Eiselsberg,  1898. — Constriction  admitting  the  little 
finger  in  the  pyloric  third  of  the  stomach.  Gastroplasty  ;  tw^elve 
months  later  gastro-enterostomy.  Recovery  from  both  operations. 
Symptoms  recurred  nine  months  after  the  first  operation.  {Archiv 
fiir  Klinische  Chimrgie,  Band  lix.) 

Case  20:  Eiselsberg,  1898. — Circular  constriction  nearer 
cardiac  than  pylorus.  Three  operations — two  gastro-plastic,  one 
gastro-gastrostomy ;  intervals  were  four,  nine  and  two  months. 
Recovery  from  operations,  but  recurrence  of  symptoms  after  all. 
(Archiv  fiir  Klinische  Chimrgie,  Band  lix.) 

Case  21  :  Eiselsberg,  1899. — Constriction  admitting  the 
passage  of  one  finger,  due  to  circular  cicatrix  and  adhesions  to 
liver.  Gastroplasty.  Recovery  with  entire  relief.  [Archiv  fur 
Klinische  Chimrgie,  Band  lix.) 

Case  22  :  Eiselsberg,  1899. — Circular  constriction  nearer 
cardiac  than  pylorus  ;  dense  mass  of  adhesions  from  constricted 
portion  of  stomach  to  liver.  Gastro-enterostomy.  Recovery  and 
complete  relief.     [Archiv  fiir  Klinische  Chimrgie,  Band  lix.) 

Case  23  :  Vox  Unge,  1898. — A  circular  constriction  admitting 
forefinger  8  centimetres  from  pylorus.  Gastroplasty.  Recovery. 
(Centralblatt  fiir  die  Grenzgehiete  der  Medicin  iind   Chimrgie,  May, 

1899-) 

Case  24  :  Von  Unge,  1898. — A  circular  constriction  admitting 
forefinger  10  centimetres  from  pylorus;  a  mass  of  adhesions. 
Gastroplasty.  Recovery.  [Centralblatt  fiir  die  Grenzgehiete  der 
Medicin  iind  Chimrgie,  May,  1899.) 

Case  25  :  Hastings  Gilford,  1898. — Hour-glass  stomach  ; 
the  constriction  barely  admitted  one  finger.  On  the  cardiac  side 
of  the  constriction  an  ulcer  had  perforated  and  formed  an  adven- 
titious cavity.     Gastroplasty.      Died  one  month  after  operation 


1 88  SURGERY  OF  THE  STOMACH 

from  haematemesis.  The  wound  in  the  stomach  was  partially 
unhealed  at  the  point  of  thickest  induration.  [Guys  Hospital 
Reports,  vol.  lih.,  1898.) 

Case  26:  Courmont,  1898. — Hour-glass  stomach.  Gastro- 
plasty. Recovered.  (Hochenegg,  Wiener  Klinische  Wochenschrift, 
1898.) 

Case  27  :  Cumston,  1898. — Constriction  at  the  junction  of  the 
middle  and  lower  thirds  ;  adhesions  to  surrounding  structures. 
Gastroplasty.  Recovery  ;  well  eight  months  after.  {Neii'  York 
Medical  Journal,  1 899.) 

Case  28 :  Hochenegg,  1898. — Constriction  at  junction  of 
middle  and  pyloric  thirds,  admitting  little  finger ;  cardiac  portion 
immensely  distended.  Gastro-gastrostomy.  Recovery.  [Wiener 
Klinische  Wochenschrift,  1898.) 

Case  29:  Bier,  1898. — -Female,  aged  fifty-one.  Ten  years' 
history  of  stomach  trouble,  loss  of  weight,  pain,  vomiting  ;  never 
hffimatemesis.  Gastroplasty.  Ulcer  near  lesser  curvature  ;  the 
cardiac  pouch  much  dilated.     Recovery. 

Case  30:  Bier,  1898. — Female,  aged  twenty-nine.  Stomach 
troubles  since  ten  years  old.  Haematemesis ;  constant  pain. 
Stomach  dilated  to  3  fingers'  breadth  below  umbilicus.  Narrowing 
of  pylorus  found  at  operation  ;  gastro-duodenostomy  ;  death.  At 
the  post-mortem  an  hour-glass  stomach,  the  pyloric  complement 
of  which  had  been  mistaken  for  the  whole  stomach. 

Case  31  :  Bier,  1898. — Female,  aged  thirty-nine.  Stomach 
trouble  since  childhood — vomiting,  pain,  etc.  Above  the  um- 
bilicus an  area  of  resistance  and  tenderness  ;  the  greater  curva- 
ture descends  i  inch  below  the  umbilicus.  At  the  operation  a 
tumour  the  size  of  a  hen's  egg  found  in  the  middle  of  the  stomach 
adherent  to  the  anterior  abdominal  wall ;  tumour  excised,  and 
found  to  consist  of  induration  round  a  chronic  ulcer.  Gastro- 
plasty.    Recovery. 

Case  32:  Bier,  1898. — Male,  aged  fifty-six.  Since  twelve  and 
a  half  years  of  age  stomach  trouble.  In  the  epigastrium  a  tumour 
the  size  of  a  man's  fist ;  found  on  exploration  to  be  due  to  adhesion 
of  stomach  and  cedema  of  abdominal  wall.  An  ulcer  in  anterior 
wall  between  curvatures,  which  in  its  contraction  had  caused  an 
hour-glass  stomach.  Excision  of  ulcer  ;  gastroplasty.  Death. 
(Cases  29  to  32  are  related  in  a  thesis  by  Eduard  Asbeck.  Vier 
Fdlle  von  Sanduhrmagen,  Kiel,  1898.) 

Case  33  :  Morse. — Male,  aged  sixty.  Pain  in  stomach  for 
twenty  years.  Hour-glass  stomach  with  large  cardiac  pouch  ; 
adhesions  between  liver  and  constriction.  Gastrolysis  ;  gastro- 
plasty.    Recovery.     [Lancet,  May,  1899.) 

Case  34  :    MacGillivray. — Woman,  aged  twenty-four.     For 


777^5"  COMPLICATIONS  OF  GASTRIC  ULCER  189 

several  years  continuous  indigestion,  severe  pain  and  vomiting, 
once  hasmatemesis.  Sudden  seizure,  pain  and  collapse.  On 
opening  abdomen  an  hour-glass  stomach,  with  perforation  of  an 
ulcer  near  lesser  curvature.  Gastroplasty.  Recovery.  {Scottish 
Medical  and  Surgical  Journal,  July,  i8gg.) 

Case  35:  Watson,  1900. — Perforating  ulcer,  with  perigastric 
abscess  and  a  mass  of  adhesions  at  the  junction  of  the  middle  and 
lower  thirds  ;  stricture  admitting  one  finger.  Ulcer  inverted  and 
sutured  ;  gastrolysis.  Death  on  fourth  day  from  general  septic 
peritonitis.     [Annals  of  Stirgery,  ]\Ay,  1900.) 

Case  36:  Klein,  1900. — Hour-glass  stomach,  the  result  of 
cicatricial  contraction  following  the  drinking  of  corrosive  fluid. 
Gastro-duodenostomy.  Recovery  and  entire  relief.  {Wiener 
Klinisclie  Rundschau.) 

Case  37:  Sidney  Martin  and  Bilton  Pollard,  1900. — Hour- 
glass contraction  and  stenosis  of  pylorus.  At  the  first  constriction 
there  was  a  small  perigastric  abscess.  The  second  compartment 
was  much  larger  than  the  first.  Pylorus  very  stenosed,  and  peri- 
pyloric abscess  found,  due  to  perforating  ulcer  just  beyond  pylorus. 
Gastro-jejunostomy.  The  second  compartment  of  the  stomach 
united  to  the  intestine.  Death  on  fifth  day.  {British  Medical 
Journal,  vol.  ii.,  1900.) 

Case  38:  Childe,  1901. —  Hour-glass  stomach.  The  cardiac 
portion  lay  under  cover  of  the  ribs,  and  was  not  noticed  until  the 
necropsy.  The  pyloric  portion  was  supposed  to  be  the  whole 
stomach,  and  'was  not  abnormally  large.'  Gastro-enterostomy 
between  pyloric  segment  and  jejunum.  Death  on  fifth  day. 
{British  Medical  Journal,  vol.  ii.,  1901.) 

The  following  is  a  complete  list  of  all  our  cases  : 

Hour-glass  Stomach  due  to  Simple  Disease. 

Case  i. — Mrs.  S.  W.  Seen  at  infirmary.  Nine  years  ago 
pain  and  vomiting.  Three  years  ago  pain  and  vomiting.  One 
year  ago  pain  and  vomiting.  Never  free  from  pain  since  last 
attack.  Then  symptoms  of  perforation.  Epigastrium  very 
tender.  Hour-glass  stomach.  Adhesions  to  abdominal  wall, 
and  on  separation  perforation  found.  Operation  May  18,  1899 
(gastroplasty).  Bone  bobbin.  Constriction  in  centre  of  stomach. 
June  26,  weight  6  stones  7  pounds  ;  July  29,  7  stones  2  pounds. 

Case  2. — Miss  P.,  aged  thirty.  Seen  with  Dr.  Duncan,  Clay 
Cross.  Fifteen  years'  history  of  ulcer.  Hsematemesis  ten  years 
before.  Patient  an  invalid.  Stomach  trifid.  Operation  June  6, 
1899  (gastroplasty — bone  bobbin — and  separation  of  adhesions). 
Recovery.     August  6,  1899,  was  well,  and  had  gained  2  stones. 


I90  SURGERY  OF  THE  STOMACH 

Case  3. — Mr.  E.  M.,  aged  twenty-three.  Seen  at  infirmary. 
Two  years'  pain  and  vomiting  after  food.  Has  lost  2  stones  in 
weight.  Tender  epigastrium.  Dilatation  of  stomach.  Splash- 
ing. Operation  July  20,  1899  (gastroplasty).  Bone  bobbin. 
Constriction  2  inches  from  pylorus.  Recovery.  Out-patient 
August  24. 

Case  4. — Miss  D.,  aged  forty-eight.  Seen  wnth  Dr.  Hindle, 
Askern.  Indigestion  and  flatulency  for  twenty  years.  Free 
haematemesis  tw^o  years  before.  Great  loss  of  flesh.  Dilatation. 
Tenderness.  Operation  July  28,  1899  (gastroplasty).  Bone 
bobbin.  Extreme  contraction  one-third  distance  from  pylorus. 
Stricture  would  just  admit  tip  of  little  finger.  Recovery.  Im- 
provement and  increase  of  weight  November  i.  See  Gastro- 
enterostomy for  relapse. 

Case  5. — Mrs.  R.  D.,  aged  thirty-nine.  Seen  with  Dr.  Bailey, 
Horsforth.  Hour-glass  stomach,  the  narrow  constriction  being 
near  the  middle  of  the  stomach,  and  adherent  to  the  anterior 
abdominal  wall  over  an  area  equal  to  a  crown  piece.  On  each 
side  of  this  the  stomach  dilated,  and  seemed  to  be  anchored  by 
the  adhesion.  On  separating  the  stomach  from  the  abdominal 
wall,  an  opening  into  the  viscus  was  exposed,  and  stomach 
contents  escaped.  This  opening  was  enlarged  transversely,  and 
the  wound  and  fistula  stitched  up  vertically.  An  omental  graft 
was  brought  to  cover  in  the  sutured  area,  in  order  to  guard 
against  future  anchoring.  Ten  years  ago  an  illness  characterized 
by  profound  anaemia.  Seven  months  ago  clear  symptoms  of 
ulcer  of  the  stomach,  but  neither  then  nor  at  any  time  any  acute 
illness  suggestive  of  perforation.  Now  vomits  after  all  ordinary 
food,  and  more  often  than  not  even  after  small  quantities  of  fluid 
food.  Pain  after  food  is  exceedingly  severe.  On  examination  of 
abdomen  a  dilated  stomach  can.  be  felt.  At  a  point  a  little  to  the 
left  of  the  middle  line,  and  slightly  below  the  ensiform  cartilage, 
is  an  area  2  inches  in  diameter,  which  is  markedly  tender,  and 
offers  increased  resistance  on  palpation.  This  area  was  found, 
at  the  operation,  to  correspond  precisely  with  the  area  of  stomach 
adhesion.  Patient  has  lost  weight,  and  deteriorated  seriously  in 
general  health  during  the  last  few  months.  Recovery.  For  a 
month  after  the  operation  pain  at  times  and  loss  of  appetite. 
Since  then  has  been  free  from  pain  and  in  excellent  health. 
Appetite  and  digestion  good. 

Case  6. — Miss  S.,  aged  fifty-two.  Seen  with  Dr.  Walker, 
Huddersfield.  Twenty-six  years'  history  of  ulcer.  Vomiting. 
Great  dilatation.  Pain.  Tenderness.  Operation  September  i, 
1899.  Hour-glass  contraction  centre  of  stomach.  Stricture  just 
admitting  a  No.   7   catheter.     Great  thickening.     Gastroplasty. 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  191 

Bone  bobbin.  Recovery.  November  i,  1899,  had  gained 
26  pounds.     Well  1901. 

Case  7. — Mrs.  A.  P.,  of  Keighley,  aged  thirty-six.  Seen  at 
infirmary.  Ten  years'  history.  Dilated  hour-glass  stomach 
diagnosed   by  lavage,    etc.     Great   vomiting.     Weight   7  stones 

1  pound.  Contraction  of  pylorus  and  also  hour-glass,  very  con- 
tracted stomach,  generally  ulcerated.  Operation  October  5,  1899 
(pyloroplasty  and  gastroplasty).  Two  bobbins.  Died  fourth  day 
after  second  operation. 

Case  8. — Miss  W.,  aged  twenty-seven.  Seen  with  Dr.  Ellis 
of  Halifax.  Eight  years'  symptoms.  Pain  two  hours  after  food 
and  vomiting.  Lost  a  stone  in  two  years.  Contraction  just 
admitting  tip  of  finger  3  inches  from  pylorus.  Operation 
March  21,  1900  (gastroplasty).  Bone  bobbin.  Recovery  1900. 
Several  pounds  heavier  than  before  operation. 

Case  9. — Mrs.  M.  B.,  aged  twenty-nine.  Seen  at  infirmary. 
Four  years'  history  of  pain  and  vomiting.  Haematemesis  and 
melena.  Hour-glass  stomach.  8  stones  9  pounds.  Opera- 
tion March  22,  1900.  Recovery  April  30.  Weight  8  stones 
\i\  pounds. 

Case  10. — Mrs.  M.  P.,  aged  twenty- seven.  Seen  with 
Dr.  Waugh,  Skipton.  Hour-glass  stomach.  The  constriction 
was  about  4  inches  from  pylorus  ;  the  passage  between  the  two 
sacs  equalled  a  No.  12  catheter  in  diameter.  There  was  marked 
induration  and  puckering,  but  no  adhesion  to  the  abdominal  wall 
or  elsewhere.  The  strictured  neck  was  divided  by  an  incision 
about  i\  inches  long  in  the  transverse  direction,  and  stitched  up 
vertically,  the  mucous  membrane  with  a  continuous  catgut 
suture,  and  the  serous  with  a  continuous  silk  suture.  Two 
additional  interrupted  sutures  were  applied  at  each  end  of  the 
wound.  No  history  of  gastric  ulcer.  Has  complained  of  irregular 
attacks  of  pain  in  epigastric  region  for  eleven  months,  always 
associated  with  the  taking  of  food,  and  coming  on  about  one  hour 
after  a  meal.  Vomiting  occasional  and  irregular,  in  rather  large 
quantities  ;  no  blood.  On  examination,  stomach  distended  and 
splashy  ;  contractions  seen  when  distended.  Medical  treatment 
has  proved  unavailing.  Operation  April  4,  1900.  Recovery. 
Vomiting  for  five  days  after  the  operation,  blood-stained.  Since 
then  perfectly  well.     Complete  recovery.     Enjoys  perfect  health. 

Case  ii. — Mr.  D.  M.,  of  Halifax,  aged  forty-four.  Seen  at 
infirmary.      Twenty    years'    history.      Dilatation.      Hour-glass 

2  inches  from  pylorus.  Operation  June  7,  1900  (gastroplasty). 
Bone  bobbin.     Recovery. 

Case  \i.- — Mr.  H.,  aged  fifty-two.  Seen  with  Dr.  Hearder, 
Ilkley.     Three  years'  history  of  pain  and  vomiting.     Epigastric 


192  SURGERY  OF  THE  STOMACH 

tenderness.  Stomach  dilated.  At  operation  hour-glass  stomach, 
but  stricture  not  extreme.  Cardiac  complement  dilated.  Weight 
8  stones  6  pounds.  Operation  October  12,  1900  (posterior 
gastro-enterostomy).  Recovery.  March  4,  1901,  letter  to  say 
well.     Weight  9  stones  1 1  pounds. 

Case  13. — Three  years'  history.  In  one  attack  perforation. 
Strong  adhesions  to  liver  and  colon.  Contraction  in  centre  of 
stomach.  Operation  November  15,  1900  (posterior  gastro- 
enterostomy).    Recovery. 

Case  14. — Mr.  J.  H.,  aged  fifty-three.  Seen  at  infirmary. 
Two  years'  history.  Lost  3  stones.  Hour-glass  contraction 
3  inches  from  pylorus.  Operation  December  6,  1900  (posterior 
gastro-enterostomy).     Recovery. 

Case  15. — Mr.  E.  C,  aged  forty-five.  Seen  at  infirmary. 
Ailing  for  five  years.  Pain  in  epigastrium  radiating  to  left  chest. 
Is  worse  after  food,  pain  coming  on  '  within  half  an  hour,'  and 
lasting  for  two  to  four  hours  unless  relieved  by  vomiting.  Fre- 
quently vomited  about  an  hour  after  food.  Never  any  blood.  Lately 
the  pain  has  been  almost  constant,  aggravated  by  food,  eased  by 
vomiting.  Has  lost  2  stones  12  pounds.  Dilated  stomach.  On 
distending  with  COg,  a  notch  was  noticed  at  the  upper  border  of 
the  stomach,  and  a  tentative  diagnosis  of  hour-glass  stomach  was 
made.  Free  HCl.  A  trace  of  lactic  acid  and  a  few  rod-shaped 
bacilli.  Operation  January  24,  1901.  An  hour-glass  stomach. 
The  scar  of  the  ulcer  was  equal  in  size  to  a  florin,  was  situated 
close  to  lesser  curvature,  and  nearer  cardiac  orifice  than  pyloric. 
Much  puckering  and  induration  of  surface.  No  adhesions.  The 
index-finger  entered,  but  could  not  pass  the  stricture.  hn 
incision  3  inches  long  was  made  transversely,  and  stitched  longi- 
tudinally in  two  layers.  A  slender  adhesion  of  gall-bladder  to 
pylorus  was  divided.  Recovery.  Within  three  weeks  was  eating 
ordinary  diet. 

Case  16. — Mrs.  I.  V.,  aged  twenty-eight.  Seen  at  infirmary. 
Symptoms  of  gastric  ulcer  for  more  than  five  years.  Was  under 
treatment  at  beginning  of  illness  at  the  infirmary.  Has  been 
gradually  getting  worse.  Vomits  now  after  every  meal ;  pain 
and  vomiting  come  on  about  half-hour  to  one  hour  after  food. 
Vomit  is  very  '  sour.'  On  examination,  hour-glass  stomach.  On 
distending  with  CO^,  the  cardiac  half  increased  considerably, 
forming  a  very  large  tympanitic  area.  The  pyloric  half  distended 
but  little ;  the  division  clearly  seen.  On  auscultation  a  forcing, 
gurgling  sound  clearly  heard.  Operation  March,  igoi.  At  the 
operation  an  hour-glass  stomach.  The  cardiac  side  of  constric- 
tion much  dilated,  and  larger  than  a  normal  stomach.  Rather 
beyond  the  middle  of  the  organ  a  constriction  that  would  just 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  193 

admit  the  forefinger ;  round  constriction  much  induration  and 
many  adhesions  :  especially  noticeable  was  one  thick,  cord-like 
one  coming  from  the  liver.  This  was  divided  between  ligatures. 
Liver  was  slightly  torn  on  separating  widespread  adhesions  along 
lesser  curvature.  Below  it  on  each  side  the  stomach  sagged,  and 
between  the  two  cavities  an  anastomosis  was  made,  which  readily 
admitted  three  fingers.     Recovery  complete  and  uneventful. 

Case  17. — Miss  P.,  aged  thirty.  Seen  w^ith  Dr.  Mackenzie  of 
Burnley.  Indigestion  from  age  of  fourteen.  For  years  pain 
after  food.  Had  haematemesis  about  four  or  five  times  a  year ; 
acute  stomach  symptoms  lasting  for  six  or  eight  weeks.  Dilata- 
tion to  level  of  the  pylorus ;  after  CO2  to  i\  inches  below. 
Tenderness.  Irregular  outline  on  distension.  Has  not  had  a 
good  meal  for  eighteen  months.  Very  thin  and  feeble.  Opera- 
tion April  2,  1901.     Stricture  near  cardiac  orifice.     Recovery. 

Case  18. — Mr.  J.  A.,  aged  fifty-five.  Seen  at  infirmary. 
Stomach  troubles  for  sixteen  years.  At  first  pain  after  food 
and  occasional  vomiting.  Five  years  ago  an  acute  attack  of 
haematemesis,  melena,  and  general  swelling  of  the  body,  w^ich 
it  was  feared  might  prove  fatal  (?  perforation).  No  ease  in 
stomach  since  then,  constant  vomiting,  pain  after  every  meal, 
and  great  wasting.  Now  looks  thin,  pinched,  and  shrivelled. 
For  three  weeks  has  had  no  food,  only  sips  of  water  and  nutrient 
enemata.  On  examination,  dilated  stomach.  Free  HCl.  Opera- 
tion. Hour-glass  stomach.  At  first  was  thought  to  be  dilated 
stomach.  On  tracing  stomach  towards  pylorus,  an  extremely 
narrowed  isthmus  (barely  as  thick  as  the  little  finger)  was  come 
to,  which  was  supposed  to  be  narrowed  pylorus,  but  on  tracing 
beyond  it  stomach  still  found.  On  invaginating  a  finger  from 
each  side  of  constriction,  no  opening  could  be  felt.  Many  ad- 
hesions separated  until  all  was  clear  and  free.  Then  incision 
into  stomach  on  cardiac  side  of  isthmus,  and  a  probe-director 
passed  through  constriction,  which  it  fitted  snugly,  the  opening 
being  no  bigger  than  a  No.  4  or  No.  5  catheter.  Gastroplasty 
performed.  On  pyloric  side  of  stricture  a  column  of  mucous 
membrane,  forming  a  bridle  stricture.  This  was  ligatured,  cut 
each  end,  and  removed.  Recovery  complete. 
Total :  eigfhteen  cases.     One  death. 


13 


CHAPTER  XII 
THE   COMPLICATIONS    OF   GASTRIC  ULCER  {continued) 

Dilatation  of  the  Stomach. 

Though  gastrectasis  is  by  some  authors  only  treated  as  a 
symptom,  it  is  one  of  such  importance  that  in  many  cases  it 
may  truly  be  said  to  be  a  disease  in  itself;  this  is  certainly 
the  case  in  that  serious  and  often  fatal  form  known  as  '  acute 
dilatation.' 

A  medical  friend,  whose  practice  lies  among  mill-operatives, 
told  us  that  a  moderate  degree  of  dilatation  was  almost  a 
constant  symptom  among  them,  owing  to  their  living  so  much 
on  tea  and  farinaceous  food  ;  and  it  is  generally  know^n  that 
well-marked  dilatation  is  usually  seen  in  gross  feeders,  or  in 
those  living  almost  solely  on  bulky  farinaceous  food,  such  as 
potatoes.  The  capacity  of  the  stomach  cannot  therefore  be 
taken  as  a  guide  in  estimating  the  dilatation  that  should  come 
under  the  notice  of  the  surgeon,  and,  in  fact,  it  is  only  in  the 
well-marked  cases  that  a  surgical  opinion  is  sought.  Un- 
fortunately, the  aid  of  surgery  is  too  frequently  put  off  until 
extreme  emaciation  has  ensued  and  the  patient  is  almost 
moribund. 

The  causes  of  dilatation  of  the  stomach  are  : 
I.  Mechanical  obstruction  at  the  pylorus,  or  near  it,  or  in 
the  duodenum — {a)  from  cicatrization  of  a  simple  ulcer  at  or 
near  the  pylorus ;  {h)  from  cancer  of  the  pylorus  ;  (c)  from 
perigastritis  leading  to  stricture  or  to  kink  of  the  pylorus  ; 
{d)  from  hypertrophy  of  the  pylorus  and  spasm  as  a  sequel  of 
ulceration,  which  may  continue  long  after  the  original  ulcer 
has  disappeared  ;  {e)  from  fibroid  thickening  of  the  pylorus ; 
(/)   from  polypus ;    {g)    from   congenital   stenosis ;    ih)  from 


J  HE  COMPLICATIONS  OF  GASTRIC  ULCER  195 

tumour  outside  the  pylorus  ;  {i)  from  pressure  on  the  duo- 
denum by  chronic  pancreatitis  when  the  head  of  the  pancreas 
is  embracing  the  duodenum;  and  (7)  from  pressure  of  mesen- 
teric vessels  as  they  cross  the  duodenum,  (k)  Terrier  records 
two  cases  of  pyloric  obstruction  due  to  gall-stone  ulcerated 
through  the  gall-bladder  into  the  pylorus.  (/)  Bartels  and 
W.  H.  Bennett  record  cases  of  gastric  dilatation  dependent 
upon  the  dragging  of  a  movable  right  kidney  producing  a 
kink  of  the  pylorus,  a  condition  which  can  be  relieved  by 
nephrorrhaphy  {Brit.  Med.  Jour.,  February  3,  igoo).  im)  From 
kink  due  to  gastroptosis  (q.v.). 

2.  Dilatation  from  atony  from  various  causes  not  me- 
chanical, but  persisting  after  the  original  cause  has  ceased 
to  act. 

3.  Acute  dilatation  from  causes  not  yet  well  understood. 

Diagnosis. 

Although  in  cases  brought  before  the  notice  of  the  surgeon 
the  diagnosis  is  usually  already  made,  he  will  need  to  verify 
its  correctness  for  himself,  and  if  possible  to  arrive  at  the 
probable  cause.  Where  there  is  great  dilatation,  the  stomach 
soon  becomes  also  displaced  downwards.  Dilatation  is  always 
accompanied  by  diminished  passage  of  the  stomach  contents 
onward,  and  is  usually  associated  with  vomiting,  the  vomiting 
differing  from  that  which  occurs  in  any  other  condition.  For 
instance,  it  does  not  occur  after  meals,  nor  even  every  day, 
but  usually  every  second  or  third  day,  and  more  frequently  at 
night  than  in  the  day ;  and  when  the  vomiting  occurs,  it  is, 
as  a  rule,  in  large,  or  even  in  enormous,  quantity,  the  vomit 
consisting  of  fermented  material  with  mucus,  andsarcinse  and 
yeast  cells  are  usually  present.  When  the  dilatation  is  de- 
pendent on  ulcer,  the  vomiting  may  be  very  acid,  owing  to  the 
presence  of  excess  of  fpee  hydrochloric  acid.  If,  however,  the 
dilatation  is  dependent  on  cancer,  the  acidity  is  due  to  lactic 
acid,  and  hydrochloric  acid  will  be  in  small  quantity  or  absent. 
Though  patients  with  dilated  stomach  do  not,  as  a  rule, 
vomit  after  food,  they  complain  of  a  sense  of  heaviness  and 
discomfort,  and  have  flatulent  eructations,  these  symptoms 
becoming  more   and   more  intense  as  the  stomach  contents 

13—2 


196  SURGERY  OF  THE  STOMACH 

accumulate,  until  relief  is  obtained  by  vomiting.  As  a  rule, 
the  first  sign  noticed  in  stomach  dilatation  is  the  splash  on 
succussion  of  the  abdomen,  this  being  the  more  marked  the 
greater  the  capacity.  If  the  patient  has  previousl}'  vomited, 
the  stomach  splash  may  be  absent,  but  it  is  usually  obtained 
b}'  allowing  him  to  drink  freely  of  warm  water.  Constipation 
and  diminished  secretion  of  urine  are  nearly  always  present. 
Where  the  obstruction  is  mechanical,  visible  peristalsis  from 
left  to  right  can  frequently  not  only  be  felt,  but  observed 
through  the  abdominal  wall ;  and  if  visible  peristalsis  be 
present,  it  is  alwa3^s  indicative  of  considerable  pyloric  obstruc- 
tion, which  will  probably  only  yield  to  surgical  treatment. 
Loss  of  flesh,  diminution  of  body  temperature,  coldness  of  the 
hands  and  feet,  and  general  feebleness,  are  characteristic  of 
the  later  stages.  Tetany  is  sometimes  present,  and  if  well 
marked  may  even  lead  to  a  fatal  termination  ;  but  before  this 
stage  is  reached,  cramps  in  the  muscles  of  the  forearm  and 
drawing  inwards  of  the  thumb — otherwise  a  tetanoid  con- 
dition— are  usually  noticed.  The  amount  of  dilatation  may  be 
ascertained  by  distending  the  stomach  with  air  introduced 
through  a  tube  and  pumped  into  it  by  means  of  a  Higginson's 
syringe.  This  can  be  done  with  very  little  discomfort  and 
without  danger.  A  simpler  method  which  we  frequently 
employ  is  to  give  a  dose  of  tartaric  acid  in  water,  imme- 
diately after  one  of  carbonate  of  soda,  when,  if  the  patient  is 
recumbent,  inspection,  palpation  and  percussion  show  the 
increase  in  size  of  the  organ. 

As  to  the  cause  of  dilatation,  the  history  materially  helps. 
If  it  be  simple,  the  history  is  usually  a  question  of  years,  but 
if  malignant,  of  months  only ;  but  in  the  latter  case  a  tumour 
is  much  more  frequently  present  than  in  the  former,  and  an 
examination  of  the  stomach  contents  after  a  test-meal  is  also 
of  service.  In  dilatation  from  ulcer,  there  will  be  usually  a 
long  histor}^  of  ulceration,  possibly  with  vomiting  of  blood, 
but  it  is  quite  possible  for  an  ulcer  of  the  pylorus  to  pursue  a 
quiet  course  and  for  a  long  history  to  be  absent.  That  peculiar 
form  of  dilatation  known  as  acute  may  apparently  occur  as  a 
result  of  spasm  without  organic  pyloric  obstruction.  It  is 
highl}.'  probable  that  nearl}'  every  case  of  extreme  dilatation 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  197 

of  the  stomach  has  some  mechanical  explanation,  and  can 
only  be  efficiently  treated  by  surgical  means.  We  know  that 
this  view  is  one  which  will  raise  some  criticism,  but  we  think 
that  time  will  prove  that  the  statement  is  correct.  We  do 
not  of  course  refer  to  those  cases  of  moderate  dilatation  which 
are  so  commonly  seen,  and  which  are  associated  with  atonic 
conditions  and  with  chronic  catarrh,  but  to  the  cases  of 
dilatation  producing  the  characteristic  symptoms  just  men- 
tioned. 

Treatment. 

The  treatment  in  any  form  of  gastrectasis  will  at  first  be 
medical  and  general,  but  if  in  a  short  time  weight  and 
strength  be  not  definitely  gained  and  maintained,  with  relief 
to  pain  and  discomfort,  then  time  should  not  be  wasted  by 
persisting  with  lavage  and  medical  treatment  for  months, 
until  the  vital  powers  have  become  sapped  and  the  patient 
reduced  to  the  last  extremity  of  exhaustion,  before  surgical 
treatment  is  advised. 

Surgical  Treatment. — If  the  contents  are  offensive,  the 
stomach  should  be  washed  out  for  a  day  or  two  before  opera- 
tion ;  and  during  twelve  or  twent3'-four  hours  rectal  injections 
may  with  advantage  supplement  light  stomach  feeding.  The 
last  lavage  should  be  a  few  hours  before  operation.  A  sub- 
cutaneous injection  of  10  minims  of  liquor  strychninse  (B.P.) 
may  with  advantage  be  given  just  before  the  operation,  so  as 
to  forestall  shock,  vv^hich  may  also  be  further  lessened  by 
giving  a  pint  of  saline  solution  by  the  rectum,  and  by  opera- 
ting on  a  heated  operating-table.  After  exposing  the  stomach 
by  an  incision  in  or  near  the  linea  alba  above  the  umbilicus, 
a  diagnosis  of  the  cause  will  be  speedily  made  by  inspection  and 
palpation  of  the  stomach  and  pylorus.  If  there  be  stricture 
of  the  stomach  itself,  either  from  adhesions  caused  by  perigas- 
tritis or  from  ulcer,  leading  to  hour-glass  contraction,  it  must 
be  treated  in  one  of  the  wa3's  previously  described.  If  the 
dilatation  be  dependent  on  adhesions  of  the  pylorus,  and  these 
can  be  detached,  leaving  the  pylorus  free,  they  should  be 
dealt  with  as  described  (see  Gastrolysis).  If  there  is  a 
stricture  of  the  pylorus,   it   must  be   treated  in  one  of  the 


198  SURGERY  OF  THE  STOMACH 

several  ways  to  be  mentioned  immediately  (pylorodiosis, 
pyloroplasty,  gastro-enterostom\-  or  p}-lorectom\-),  according 
to  its  nature. 

Pylorodiosis. — If  the  narrowing  of  the  pylorus  be  due  to 
spasm  or  hypertrophy  of  the  circular  muscular  fibres,  pyloro- 
diosis, or  dilatation  of  the  pylorus,  may  be  indicated.  This 
is  known  as  Loreta's  operation,  since  it  was  he  who  first  em- 
ployed the  method  as  a  definite  operative  procedure  in  1884 
and  brought  it  before  the  profession.  But  in  1881  Richter  had 
dilated  the  pylorus  by  bougies,  and  Hahn  had  also  done  the 
same.  Hahn  also  advocated  rapid  dilatation  by  invagination 
through  the  stomach  wall.  Loreta,  however,  practised  and 
strongly  advocated  dilatation  of  the  pylorus  through  an  incision 
on  the  stomach  side  of  the  pylorus.  Through  the  opening  in 
the  stomach  he  introduced  first  the  right  and  then  the  left 
index-fingers  into  the  pyloric  orifice,  and  stretched  it  forcibly 
until  the  diameter  was  approximately  8  centimetres,  after 
which  the  stomach  wound  was  closed  by  sutures.  Bull  also 
advocated  the  use  of  bougies,  and  Barton  employed  a  uterine 
dilator  instead  of  the  fingers. 

Jaboulay,  in  a  case  of  cancer,  dilated  the  pylorus  by 
invaginating  the  stomach  wall  by  means  of  a  finger,  great 
relief  to  the  patient  resulting.  This  all  sounds  very  simple, 
and  when  we  hear  of  Loreta  having  had  twenty-nine  cases 
all  successful,  it  would  seem  that  the  operation  does  all  that 
could  be  desired  ;  but  there  is  another  side  to  the  picture, 
when  we  hear  that,  in  the  hands  of  many  able  surgeons,  this 
apparently  simple  operation  has  such  a  high  rate  of  mortality 
as  40  per  cent.,  and  that  Loreta  himself  confessed  to  having 
had  several  deaths  from  haemorrhage  and  peritonitis.  More- 
over, recurrence  of  the  stricture  seems  to  have  occurred  in 
so  large  a  number  of  cases  that  the  operation  is  scarcely 
likely  to  hold  its  own  in  competition  with  the  more  exact 
and  safer  operations  of  pyloroplasty  and  gastro-enterostomy. 
It  probabty  has  some  use  in  that  very  limited  class  of  cases 
where  the  stenosis  is  simple  and  dependent  on  spasm  of  the 
sphincter,  which  may  either  be  caused  by  ulceration  or  occur 
independently  of  such  a  condition.  A  case  has  been  related 
by  Mr.  Paul  {British  Medical  Journal,  i8g6). 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  199 

The  patient  was  a  man,  aged  twenty-one  years.  He  was 
admitted  into  the  Royal  Infirmary,  Liverpool,  under  the  care  of 
Dr.  Caton,  in  November,  1895,  for  pain  in  the  epigastric  region 
and  a  lump.  The  lump  proved  to  be  a  largely  dilated  stomach, 
in  which  splashing  sounds  could  be  easily  produced.  He  was 
treated  by  careful  dieting  and  washing  out  of  the  stomach  ;  but 
not  having  materially  improved  in  January,  1896,  the  case  was 
transferred  to  me.  The  patient  was  anaemic,  and  decidedly  of 
neurotic  type.  On  January  6  the  abdomen  was  found  to  be 
dilated,  the  pylorus  was  thick  but  not  fibrous,  and  upon  in- 
vaginating  the  anterior  wall  upon  the  forefinger  into  the  pyloric 
orifice  abnormal  resistance  was  met  with.  This  was  gradually 
overcome  by  continued  steady  pressure,  and  ultimately  the  open- 
ing was  overdilated  without  splitting  by  passing  three  fingers 
through  it.  No  cut  was  made  in  the  organ.  The  patient  healed 
well,  but  was  subsequently  attacked  with  acute  mania,  and  had 
to  be  sent  to  the  county  asylum,  where  he  remained  for  five 
months  before  he  got  his  discharge.  He  had  no  recurrence  of 
the  gastric  symptoms. 

We  have  had  several  cases  similar  to  the  above  in  which 
dilatation  was  successfully  done  by  invagination.  This  is, 
however,  the  operation  suggested  by  Hahn,  and  not  by 
Loreta.  Under  the  heading  Gastroplication  will  be  found 
reports  of  two  cases  in  which  Hahn's  method  of  dilating  the 
pylorus  was  adapted  successfully  by  one  of  us  (A.  W.  M.  R.) 
at  the  same  time  that  the  dilated  stomach  was  diminished 
in  volume  by  gastroplication.  In  the  chapter  on  Congenital 
Stenosis  is  also  reported  a  case  of  Hahn's  operation  which 
w^as  followed  by  relapse,  and  in  that  case  a  puckering  of  the 
pylorus  seen  at  the  second  operation  showed  that  the  stretch- 
ing had  been  followed  by  ulceration  and  stenosis. 

The  late  Greig  Smith  held  a  favourable  opinion  of  Loreta's 
operation,  but  many  surgeons  have  told  us  that  they  have 
given  up  pylorodiosis,  and  our  own  feeling  is  decidedly  in 
favour  of  pyloroplasty  where  no  active  ulceration  is  going  on 
and  where  adhesions  are  absent,  and  of  gastro-enterostomy 
where  the  pylorus  is  ulcerated. 

Statistics  of  Loreta's  Operation^ — In  the  Hunterian  Lectures 
we  collected  a  series  of  78  operations,  of  which  47  recovered, 
this  giving  a  mortality  of  39*7  per  cent. 

Pyloroplasty. — The  principle  of  the  operation  consists  in 


200  SURGERY  OF  THE  STOMACH 

obtaining  an  increase  of  the  calibre  in  a  stricture,  by  dividing 
the  narrow  passage  longitudinally  and  closing  the  wound 
transversely. 

The  operation  was  performed  first  by  Heineke  in  March, 
1886,  and  his  patient  recovered.  Mikulicz  performed  his 
first  pyloroplasty  in  1887,  but  the  patient  died ;  in  his 
second  operation  in  the  same  year  the  patient  recovered. 
Of  the  first  seventeen  operations  eleven  recovered. 

If  the  pylorus  be  free  from  adhesions  the  operation  is  of 
the  simplest,  as  the  pylorus  can  be  brought  outside  the 
abdomen  and  surrounded  by  gauze  pads  or  sponges,  so  that 
this  heavy  mortality  of  35"3  per  cent,  must  have  been  due  to 
an  improper  selection  of  cases,  as  later  results  only  show  a 
mortality  of  g  per  cent,  in  Czerny's  clinic  (Steudel)  and 
II  per  cent,  in  our  own  cases.  It  is  desirable  to  adopt  all 
the  usual  precautions  against  shock,  and  the  stomach 
should,  if  practicable,  be  washed  out  some  little  time  before 
operation,  so  as  to  avoid  the  danger  of  soiling  the  peri- 
toneum. The  incision  through  the  pylorus  must  be  longi- 
tudinal, commencing  on  the  stomach  side  of  the  sphincter, 
and  being  prolonged  through  it  either  by  scissors  or  by 
the  knife  over  a  director.  Blunt  hooks  or  catch  forceps 
placed  in  the  wound  convert  the  horizontal  incision  into 
a  transverse  one,  and  it  is  then  closed  by  a  double  line  of 
sutures. 

The  modification  of  the  operation  by  the  use  of  an  internal 
splint  in  the  shape  of  a  bone  bobbin,  over  which  to  apply  the 
sutures,  is  a  method  that  one  of  us  (Mayo  Robson)  has 
employed  in  all  his  operations,  and  one  which  offers  several 
advantages.  For  instance,  only  two  continuous  sutures  are 
required  for  the  mucous  and  peritoneal  margins  respectively. 

The  bone  tube  secures  an  immediate  and  thoroughly  patent 
channel.  It  affords  protection  for  from  twenty-four  to  forty- 
eight  hours  to  the  line  of  sutures,  by  which  time  union 
should  be  established,  and  it  prevents  the  new  channel  being 
inadvertently  made  too  narrow.  Although  the  bone  bobbin 
originally  invented  for  pylorectomy  and  enterectomy  answers 
quite  well,  a  recent  modification,  in  which  the  barrel  of  the 
bobbin  is  lengthened,  facilitates  the  operation.     This  modi- 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  201 

fication  of  pyloroplasty  has  been  followed  by  Rushton  Parker 
[British  Medical  Journal,  December  14,  1895)  and  other 
surgeons  with  success.  Illustrative  cases  have  already  been 
quoted, 

Koeppelin  [LyonMedicale,  September  24,  1899,  and  British 
Medical  Journal,  Suppl.,  January  6,  1900)  reports  a  modifica- 
tion of  the  operation  known  as  '  submucous  pyloroplasty.' 
The  horizontal  wound  along  the  pylorus  is  made  through  the 
two  outer  coats,  serous  and  muscular,  of  the  bowel,  and 
through  the  cicatrix,  if  there  be  one,  and  the  exposed  and 
unopened  mucosa  at  once  bulges  like  a  hernia.  The  divided 
coats  are  then  united  vertically,  as  in  ordinary  pyloroplasty. 
Three  reported  cases  of  the  submucous  operation  have  proved 
successful.  The  first  patient  was  a  girl,  aged  twenty-two 
years,  who  was  subject  to  spasm  of  the  pylorus.  The  second 
patient  was  a  woman,  aged  sixty  years,  who  had  suffered  from 
cancer.  Marked  relief  followed  the  operation.  Eighteen 
months  later  the  second  patient  underwent  gastro-enter- 
ostomy  with  temporary  benefit.  Jaboulay  of  Lyons  per- 
formed the  third  submucous  pyloroplasty  in  June,  1899. 
The  patient  was  a  man,  aged  forty-two  years,  who  had 
suffered  eight  years  previously  from  symptoms  of  gastric 
ulcer,  followed  later  by  evidence  of  pyloric  obstruction.  He 
at  length  vomited  incessantly,  suffered  from  intense  pain 
which  necessitated  large  doses  of  morphia,  and  became  very 
thin.  At  the  operation  cicatricial  stricture  of  the  pylorus 
was  discovered.  The  cure  was  complete.  Koeppelin  main- 
tains that  this  modification  is  safer  than  the  older  pyloro- 
plasty. The  advantage  lies  in  the  avoidance  of  opening  the 
stomach  cavity.  As  lessening  the  danger  of  sepsis,  the 
modification  may  be  occasionally  employed,  but  it  should 
certainly  never  be  performed  in  the  presence  of  ulcer  or 
cancer  of  the  pylorus. 

If,  owing  to  the  cicatrization  of  the  ulcer,  there  be  extensive 
hypertrophy  of  the  pylorus,  with  a  large  amount  of  thicken- 
ing, pyloroplasty  is  insufficient,  as  in  such  cases  contraction 
will  be  likely  to  recur.  Here  pylorectomy  may  be  performed, 
as  in  cases  already  related;  or,  better  still,  gastro-enterostomy, 
which  is  a  simpler,  quicker,  and  safer  operation.     Numerous 


202  ■  SURGERY  OF  THE  STOMACH 

and  firm  adhesions,  active  ulceration,  and  the  presence  of 
new  growth,  are  also  contra-indications  for  pyloroplasty. 

Dr.  Maurice  Richardson  (Boston  Medical  and  Surgical 
Journal,  November  30,  1899)  advocates  partial  excision  of  the 
stricture  where  there  is  extensive  thickening  and  well-marked 
stricture,  as  in  the  following  case  in  a  man  aged  fifty-four 
years.  The  pylorus  was  extensively  thickened  and  tightly 
constricted.  The  longitudinal  incision  was  made  for  3  inches 
through  the  stomach,  the  stricture,  and  the  pylorus.  The 
incision  was  converted  into  a  lozenge  shape  or  a  broad  V  by 
removing  a  considerable  portion  of  the  cicatrix  of  the  anterior 
wall  of  the  pylorus.  By  bringing  together  the  opposing 
surfaces  of  the  duodenum  and  the  stomach,  a  wide  lumen  was 
procured.  The  mucous  membrane  was  first  united  by  a  con- 
tinuous suture,  and  the  peritoneum  by  an  interrupted  silk 
Lembert's  suture.  The  patient  was  in  good  health  five 
months  later.  This  pyloroplast}'  with  partial  excision  seems 
to  be  the  right  practice  in  some  cases  of  bad  organic 
stricture  and  in  active  ulcer  of  the  pylorus. 

The  dense  tissue  being  cut  away,  the  lozenge-shaped 
incision  can  be  readily  sutured  so  as  to  become  transverse ; 
while  if  a  simple  longitudinal  incision  is  made  through  the 
tissues  of  a  dense  stricture,  it  is  impossible  to  convert  it 
safely  into  a  transverse  line  of  sutured  wound  owing  to  the 
great  tension  if  the  two  ends  be  made  to  meet  in  the  middle. 
A  case  of  ours  reported  under  Excision  of  Ulcer,  is  a  good 
example  of  this  method  of  performing  pyloroplasty. 

If  on  opening  the  stomach  or  pylorus  a  polypus  be  found 
as  a  cause  of  the  obstruction,  it  must  be  removed,  and,  if 
necessary,  the  operation  can  be  completed  by  a  p3doroplasty. 

Dilatation  dependent  on  Pressure  outside  Pylorus. — If  the 
dilatation  be  dependent  on  an  obstruction  outside  the  stomach 
— as,  for  instance,  a  tumour  of  the  pancreas,  liver,  or 
gall-bladder — relief  may  be  given  by  removing  the  tumour, 
or,  if  that  be  impracticable,  by  gastro-enterostomy.  The 
instance  reported  by  Dr.  Ewart  and  Mr.  Jaffrey  {Lancet, 
October  28,  i8gg,  p.  1155)  is  a  case  in  point,  where  vomiting, 
incapable  of  relief  by  medical  means,  was  dependent  on  an 
aneurism  flattening  out  the  p3'loric  end  of  the  stomach  and 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  203 

causing  obstruction.     The  following  is   an   account   of  the 
operation,  with  remarks  by  Mr.  Jaffrey : 

Dr.  Ewart  asked  me  to  see  this  case  in  consultation  with  him 
on  August  26.  There  was  a  swelling  midway  between  the 
umbilicus  and  the  ensiform  appendix,  which  appeared  to  me  to 
pulsate  more  freely  than  one  would  expect  from  a  growth  of  the 
stomach  lying  over  the  aorta.  However,  taking  into  considera- 
tion the  symptoms  and  the  swelling,  we  agreed  that  an  exploratory 
laparotomy  should  be  done.  This  I  did  on  the  following  day.  I 
made  an  incision  from  4  to  5  inches  long  above  the  umbilicus. 
The  stomach  presented  in  the  wound,  and  on  examination  it  was 
found  to  be  quite  healthy,  though  dilated.  On  pulling  the 
stomach  out  of  the  wound,  there  appeared  to  be  between  from 
\  pint  to  I  pint  of  fluid  collected  in  the  most  dependent  part  of 
the  fundus.  The  colon  appeared  to  be  normal,  and  the  walls  of 
the  stomach  did  not  appear  to  be  materially  thinned.  I  attempted 
to  press  some  of  the  fluid  into  the  duodenum,  but  did  not  succeed 
in  getting  much  to  pass,  and  on  further  examination  the  swelling 
which  we  had  felt  through  the  abdominal  walls  proved  to  be  a 
large  fusiform  aneurism  of  the  abdominal  aorta.  It  commenced 
about  \  inch  below  the  aortic  opening  of  the  diaphragm,  and 
extended  to  the  level  of  the  umbilicus.  The  pyloric  end  of  the 
stomach  was  flattened  over  the  convex  surface  of  the  aneurism, 
so  much  so  that  it  caused  obstruction  to  the  passage  of  the 
contents  of  the  stomach  into  the  duodenum.  This  seemed  to  me 
to  be  partly  due  to  the  weight  of  the  dilated  stomach  and  its 
contents,  and  of  the  colon  and  omentum.  I  deemed  it  advisable 
to  pull  as  much  as  possible  of  the  stomach  over  to  the  right  side 
of  the  aneurism,  so  as  to  relieve  this  pressure.  As  the  stomach 
seemed  inclined  to  remain  in  its  new  position,  I  did  not  think  it 
necessary  to  fix  it  in  any  way.  The  patient  rapidly  recovered 
from  the  operation,  the  wound  was  dressed  with  dry  cyanide 
gauze,  and  the  sutures  were  removed  on  the  eighth  day.  There 
was  slight  vomiting,  frequently  recurring  for  several  days,  in  con- 
nection with  nausea,  excited  by  the  smell  of  brandy.  The 
alarming  symptoms  disappeared,  and  the  patient  slowly  im- 
proved, and  became  able  to  take  solid  food  and  to  walk  for  short 
distances.  She  complained  of  burning  sensations  in  the  epigastric 
region,  and  had  general  hyperaesthesia  of  the  abdomen,  but  the 
pulsating  mass  was  less  easily  felt ;  this  was  no  doubt  due  to  the 
fundus  of  the  stomach  being  placed  between  the  aneurism  and 
the  abdominal  wall. 

Dilatation  due  to  Obstruction  by  Cancer  of  the  Pylorus. — 
If  cancer  of  the  pylorus  be  found  to  be  causing  the  dilata- 


204  SURGE RV  OF  THE  STOMACH 

tion,  pylorectomy  may  be  indicated  if  the  disease  be  limited 
and  there  be  no  secondary  infection  ;  but  if  it  be  too  exten- 
sive for  removal,  gastro-enterostomy  will  be  the  only  treat- 
ment likely  to  afford  relief. 

Dilatation  due  to  Pyloric  Tumour  the  Result  of  Ulcer. — 
In  some  cases  of  chronic  ulcer  with  great  thickening,  pylo- 
rectomy may  be  the  best  treatment,  and  in  others  pyloro- 
plasty, but  in  the  greater  number  of  such  cases  gastro- 
enterostomy will  be  the  operation  of  choice. 

A  case  related  elsewhere  is  a  good  example  of  a  large 
tumour  of  the  stomach  and  pylorus  producing  gastric  dilata- 
tion, in  which  one  of  us  performed  gastro-enterostomy, 
thinking  the  disease  to  be  cancer.  The  entire  disappearance 
of  the  tumour  and  the  present  well-being  of  the  patient, 
however,  prove  that  the  disease  was  inflammatory  thickening 
around  an  ulcer. 

Other  cases  of  dilated  stomach  owing  to  tumour  of  the 
pylorus  the  result  of  ulceration,  treated  by  pylorectomy, 
pyloroplasty,  and  gastro-enterostomy,  are  related  elsewhere, 
under  the  headings  of  these  various  operations. 

Dilatation  of  Stomach  due  to  Cholelithiasis  and  Consequent 
Perigastritis  around  the  pyloric  end  of  the  stomach  is  so 
common  a  sequence  of  events  that  we  have  come  to  look 
on  it  as  a  concomitant  ailment  ('  Diseases  of  Gall-bladder 
and  Bile-ducts,'  2nd  edit.,  p.  6i). 

Several  cases  out  of  many  that  we  have  had  that  were 
successfully  treated  by  gastrolysis  are  related  in  the  chapter 
on  Perigastritis.  A  case  is  also  related  in  the  chapter  on 
Fistula  where  severe  stomach  symptoms,  characterized  by 
dilatation  and  by  vomiting,  were  remedied  by  detaching 
the  gall-bladder  from  the  pylorus  and  closing  the  fistulous 
opening. 

Terrier  (' Chirurgie  de  I'Estomac')  records  two  cases  of 
pyloric  obstruction  due  to  gall-stones  ulcerating  through  the 
gall-bladder  into  the  pylorus.  In  the  chapter  on  Pylorec- 
tomy for  Cancer,  is  recorded  a  case  of  cancer  starting  in  the 
gall-bladder,  extending  to  the  pylorus,  and  producing  dilata- 
tion of  the  stomach,  in  which  at  the  same  time  partial 
hepatectomy,  cholecystectomy,  and   pylorectomy  were   per- 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  205 

formed  successfully  on  August  10,  igoo,  the  patient  being 
now  in  good  health  eight  months  after  operation. 

Tetany  and  Tetanoid  Spasms  in  Association  with  Gastric  Dilata- 
tion,— It  does  not  appear  to  have  been  generally  noticed  that 
severe  muscular  spasms  of  a  tetanoid  character,  in  rare  cases 
amounting  to  severe  or  even  fatal  tetany,  are  frequently  asso- 
ciated with  dilatation  of  the  stomach  ;  yet  we  have  noticed 
tetanoid  symptoms  in  so  many  cases  of  dilated  stomach  that 
we  have  come  to  look  at  it  as  a  frequent  concomitant  of  the 
disease. 

An  important  paper  on  the  subject  by  our  colleague, 
Dr.  E.  F.  Trevelyan,  published  in  the  Lancet,  September  24, 
i8g8,  p.  791,  shows  very  forcibly  that  fully-developed  tetany 
associated  with  stomach  dilatation  is  a  symptom  of  extreme 
gravity,  and  that  in  such  cases  a  fatal  termination  is  to  be 
feared.  To  quote  from  Dr.  Trevelyan's  paper  :  '  If  the  term 
"gastric  tetany"  is  allowed  to  include  the  milder  as  well  as 
the  severer  cases — and  there  is  no  sufficient  reason  against 
this  view — then  the  disease  may  turn  out  to  be  more  common 
than  is  usually  supposed.  The  transition  between  gastric 
tetany  so  called,  tetany  with  gastro-intestinal  symptoms,  and 
ordinary  tetany,  would  seem  to  be  a  gradual  one.  The  prog- 
nosis of  tetany  occurring  in  gastric  dilatation  is  undoubtedly 
very  serious — nearly  75  per  cent,  of  the  cases  die.  The  largest 
mortality  occurs  in  cases  where  the  spasm  in  the  extremities 
is  associated  with  tonic  spasms  in  the  head  and  trunk  muscles 
or  with  clonic  spasm.  If  the  very  strict  views  are  held  as  to 
the  disease,  then  the  outlook  is  almost  hopeless.  Thus,  of 
the  eleven  cases  recognised  by  Frankl  Hochwart,  only  one 
recovered.  There  is  a  danger  here,  as  in  some  other  diseases, 
that  the  fatal  issue  is  raised  to  be  the  chief  criterion  as  to  the 
nature  of  the  affection.' 

Our  own  experience  of  tetany  and  of  the  severe  muscular 
spasms  in  association  with  gastric  dilatation  leads  us  to 
think  that  we  may  possibly  take  a  more  hopeful  view  if 
the  cases  be  treated  surgically  at  an  early  period.  The 
following  cases  will  , serve  to  illustrate  our  views.  In  the 
first  case  the  tetany  was  so  pronounced  that  the  question 
of  strychnine-poisoning  crossed  our  mind.      In  the  second 


2o6  SURGERY  OF  THE  STOMACH 

and  third  cases,  though  there  were  well-marked  tetanic 
spasms,  the  cramps  were  limited  to  the  extremities  and  the 
abdomen. 

Case  i. — A  man,  aged  thirty-four  years,  was  sent  to  one  of  us 
(Mayo  Robson)  by  his  medical  attendant  in  January,  1895,  with 
a  view  to  having  something  done  in  the  Leeds  Infirmary  to  relieve 
his  condition.  He  had  been  suffering  for  five  years  from  pain 
after  the  ingestion  of  food,  with  attacks  of  vomiting.  Latterly 
his  condition  had  become  aggravated,  the  pains  occurring  from 
half  an  hour  to  one  hour  after  each  meal,  and  being  relieved  only 
by  vomiting,  so  that  for  the  last  six  months  he  had  had  to  give 
up  his  work  as  a  printer.  For  some  time  before  coming  under 
our  notice  there  had  been  very  evident  peristalsis  from  left  to 
right  in  the  epigastric  region.  Throughout  the  period  over  which 
his  stomach  symptoms  extended,  his  bowels  had  for  the  most  part 
been  very  constipated,  but  there  were  occasional  attacks  of  diar- 
rhoea. During  this  time  he  had  attacks  of  what  he  described  as 
'  cramps '  in  his  limbs,  and  especially  in  his  legs.  He  had  lost 
very  considerably  in  weight,  as  in  December,  1892,  he  weighed 
9  stones  jh  pounds. 

On  examination,  there  was  found  well-marked  dilatation  of  the 
stomach ;  but  the  feature  of  the  case  which  presented  most 
interest  in  connection  with  the  present  question  was  the  occur- 
rence while  under  observation  of  the  severe  tetanic  spasms, 
affecting  almost  all  the  muscles  of  the  body.  So  extreme  were 
these  and  so  widespread — the  muscles  of  the  trunk  and  of  the 
cervical  region,  as  well  as  those  of  the  limbs,  being  affected — 
that  on  January  17  the  question  of  possible  strychnine-poisoning 
was  raised.  As  palliative  treatment  of  the  stomach  condition 
gave  no  relief,  the  stomach  was  exposed  on  January  24,  and  the 
diagnosis  of  cicatricial  stenosis,  with  hypertrophy  of  the  pylorus, 
was  confirmed.  Pyloroplasty  was  done,  a  bone  bobbin  being 
employed  to  insure  patency  of  the  new  pylorus.  Recovery  was 
uninterrupted,  and,  although  the  cramps  were  present  up  to  the 
time  of  operation,  he  never  had  even  a  threatening  of  cramp 
afterwards.  On  February  15  he  was  able  to  take  a  mutton  chop 
for  his  dinner  without  inconvenience,  and  by  March  2  (five  weeks 
after  the  operation)  he  had  gained  8|  pounds.  Since  then  he  has 
done  very  well,  and  two  years  after  the  operation  he  had  quite 
recovered  his  strength,  and  was  working  as  usual,  his  weight  then 
being  just  over  what  it  was  in  December,  1892,  and  quite  2  stones 
above  what  it  was  at  the  time  of  the  operation.  There  had  been 
no  recurrence  of  any  '  cramps  '  or  of  muscular  spasms  of  any  kind. 
In  a  letter  received  at  the  beginning  of  1899,  he  speaks  of  some 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  207 

stomach  disorder,  but  he  adds  :  '  You  will  please  understand  that 
I  am  a  new  man  to  what  I  was  when  you  saw  me  last.' 

Case  2. — A  man,  aged  twenty-four  years,  was  seen  by  one  of 
us  (Mayo  Robson)  on  October  5,  1897,  in  consultation  with  his 
private  medical  attendant,  on  account  of  severe  painful  cramps 
of  the  extremities  and  of  the  abdomen,  with  persistent  vomiting. 
He  gave  the  history  of  having  had  pain  after  food  for  several 
years  previously,  and  of  having  vomited  blood,  since  which  time 
he  had  never  been  well  and  had  gradually  lost  flesh.  For  some 
little  time  before  we  saw  him  he  had  vomited  every  day,  unless 
the  stomach  was  washed  out,  and  from  weighing  over  10  stones 
he  had  diminished  to  a  little  over  8  stones.  There  was  well- 
marked  dilatation  of  the  stomach,  but  no  pyloric  tumour  could 
be  felt,  and  simple  stricture  of  the  pylorus  was  diagnosed.  He 
was  admitted  to  the  infirmary  in  October,  and  on  the  21st 
pyloroplasty  was  performed,  as  the  pyloric  orifice  would  only 
permit  the  passage  of  a  No.  10  catheter.  The  longitudinal 
incision  in  the  pylorus  was  sutured  vertically  over  one  of  the 
bone  bobbins.  Recovery  was  uninterrupted,  and  from  that  time 
the  cramps  and  vomiting  ceased.  He  returned  home  w^ithin  a 
month.  On  October  23,  1898,  the  following  letter  was  received 
from  him :  '  It  is  with  a  grateful  heart  I  write  to  thank  you  for 
the  good  received  at  your  hands  twelve  months  ago.  I  am 
thankful  to  say  I  have  never  had  any  trouble  with  my  stomach 
since.  I  feel  it  my  duty  to  acknowledge  the  good  I  received,  and 
also  to  thank  you  for  your  extreme  kindness.' 

Case  3. — A  woman,  aged  twenty-nine  years,  was  sent  to  one  of 
us  (Mayo  Robson)  from  the  East  Coast,  in  the  spring  of  1895, 
suffering  from  severe  pain  in  the  abdomen,  associated  with 
vomiting  and  loss  of  flesh.  There  was  well-marked  dilatation 
of  the  stomach,  and  the  pain  always  started  on  the  left  side  of 
the  abdomen  and  passed  to  the  right,  on  which  side,  just  below 
the  ninth  rib,  there  was  well-marked  tenderness,  with  rigidity  of 
the  right  rectus  muscle.  Operation  was  declined,  and  we  did  not 
see  the  patient  until  nearly  the  end  of  the  year,  when  she  said  that 
the  pain  in  the  abdomen  was  excruciating  and  recurred  every 
day.  She  said  it  was  associated  with  severe  cramp  in  the  limbs, 
especially  in  the  legs  and  thighs,  and  that  at  night  she  was  kept 
awake  by  the  pain.  Vomiting  of  large  quantities  occurred  daily, 
and  she  was  steadily  losing  weight  and  strength.  Her  symptoms 
began  in  1888,  and  she  had  lost  2  stones  in  weight  between  that 
year  and  1895.  On  December  14  we  opened  the  abdomen,  and 
found  active  ulceration  of  the  pylorus,  which  was  adherent  to  the 
gall-bladder,  liver,  and  abdominal  walls,  and  was  so  much  thick- 
ened as  to  form  a  distinct  tumour.     Pyloroplasty  was  performed 


2o8  SURGERY  OF  THE  STOMACH 

after  the  adhesions  had  been  separated.  Recovery  was  un- 
eventful and  satisfactory  in  every  way,  and  she  returned  home 
within  the  month.  She  had  never  any  return  of  the  tetanic 
symptoms,  and  a  report  sent  in  March  was  to  the  effect  that  she 
had  gained  flesh  and  was  'well."  In  July,  1S96,  we  saw  her 
again  for  stomach  symptoms,  but  without  much  loss  of  flesh.  In 
1897  and  1898  the  vomiting,  loss  of  flesh,  and  well-marked  stomach 
splash  showed  that  the  pyloric  trouble  had  recurred,  and  as  a  dis- 
tinct tumour  of  the  pylorus  was  felt,  which  was  believed  to  be 
simple  inflammatory  induration,  gastro- enterostomy  was  per- 
formed in  October,  1898.  She  made  a  good  recovery,  and  has 
been  quite  well  since.  A  letter  in  December,  1899,  states  that 
she  is  quite  Avell  and  has  fully  regained  her  weight. 

The  interesting  point  in  this  case  is  that  there  was  no 
return  of  the  painful  cramps  in  the  limbs  after  the  first 
operation. 

Though   tetany  occurs  apart  from   gastric   dilatation — for 
instance,  in  children  during  teething,  when  it  is  frequently 
associated    with    gastro-intestinal    disorders,   and    not    infre- 
quently merges  into  general  convulsions — and  in  other  con- 
ditions possibly  apart  from  stomach  disorders,  yet  tetany  or 
painful    muscular   spasms    of    a    serious    character    are    so 
frequently  associated  with  gastric  dilatation  that  one  cannot 
ignore  the  association,  and  pronounce  it  merely  accidental. 
It  is  curious  that  we  have  seldom  seen  the  symptoms  in  other 
than  dilatation  due  to  simple  causes,  such  as  adhesions  of 
the  pylorus  to  the  gall-bladder  or  liver,  or  stricture  of  the 
pylorus  due  to  the  cicatrization  of  ulcers.     We  have  seldom 
seen  it  in  simple  unobstructive  dilatation,  or  in  dilatation  due 
to  cancer  of  the  pylorus,  though  Dr.  E.  F.  Trevelyan  gives 
single   examples   of  its  association  with  both  in  his  paper  ; 
and  in  one  of  our  cases  of  cancer  tetany  was  well  marked  and 
very  distressing.    The  immediate  cause  of  tetany  is  somewhat 
obscure,  but   as  our  views   are   based  on  clinical  experience 
they  may  be  worth  mentioning.     We  have  noticed  that  the 
exacerbations  of  the  tetanic  state  (especially  in  the  first  case 
related)  were  always  associated  with  a  painful  contraction  of 
the  stomach,  and  that  when   the  wave   of  contraction   had 
reached    the   pylorus,   the    latter,  which  was    previously  in- 
capable of  being  felt,  formed  a  distinct  hard  tumour.     The 


THE  COMPLICATIONS  OF  GASTRIC  ULCER  209 

abdominal  pain  then  became  very  intense,  and  the  tetanic 
cramps  in  other  muscles  came  on,  or,  if  already  present, 
became  intensified.  From  this  sequence  of  events  we  have 
come  to  the  conclusion  that  the  cause  of  tetany  is  a  double 
one — first,  the  absorption  of  some  poison  from  the  dilated 
stomach  which  increases  the  excitability  of  the  nervous 
system  ;  and,  secondly,  a  reflex  effect  produced  by  the  painful 
contraction  of  the  pylorus.  The  practical  outcome  of  these 
observations  is  that,  where  tetany  or  allied  conditions  are 
associated  with  gastric  dilatation,  surgical  treatment  in  the 
shape  of  gastro-enterostomy  or  pyloroplasty  is  well  worth  con- 
sidering before  the  symptoms  become  so  severe  as  to  lead  to 
the  almost  hopeless  condition  described  in  the  report  of  some 
of  the  fatal  cases.  In  the  case  of  children  suffering  from 
tetany,  which  is  usually  accounted  for  by  the  irritation  of 
teething,  it  may  be  advisable  to  examine  the  size  of  the 
stomach  as  a  routine  measure  ;  for  we  suspect  that  in  many 
cases  it  will  be  found  that  there  is  dilatation  due  to  congenital 
stenosis  or  to  spasm  of  the  pylorus.  We  have  shown  else- 
where that  pyloric  trouble  in  children  and  young  adults  is 
much  more  common  than  has  been  generally  thought. 

In  the  case  of  adults  suffering  from  painful  muscular  spasm 
and  cramps  in  the  arms  and  in  the  gluteal  muscles,  it  may 
also  be  well  to  remember  the  frequent  association  of  gastric 
dilatation  and  tetany ;  for  on  several  occasions  recently 
where  we  have  been  consulted  for  these  conditions  we  have 
found  well-marked  stomach  dilatation,  previously  quite  un- 
suspected. 


14 


CHAPTER  XIII 

DILATATION  OF  THE  STOMACH  FROM  OTHER 
CAUSES 

Acute  Dilatation  of  the  Stomach. 

Acute  dilatation  was  first  described  by  Dr.  Fagge,  his  paper 
being  illustrated  by  two  cases,  both  in  men  (one  thirty  and 
the  other  twenty  years  of  age),  and  both  ending  fatally.  The 
symptoms  were  those  of  largely  distended  stomach,  coming 
on  suddenly,  accompanied  by  pain  and  diminished  secretion 
of  urine,  followed  by  death.  Many  other  cases  of  the  kind 
have  since  been  reported,  and  the  subject  was  discussed  in 
an  able  paper  by  Dr.  T.  N.  Kelynack  {Medical  Chronicle, 
May,  1892),  where  will  be  found  a  reference  to  all  cases 
previously  reported.  Pepper  and  Stengel  suggest  that  the 
immediate  cause  is  spasm  of  the  pylorus.  Carion  and  Hallion 
{Semaine  Medicate,  August  21,  1895)  have  shown  that  the 
section  of  the  pneumogastric  nerves  in  the  dog  leads  to 
dilatation  of  the  stomach,  and  to  symptoms  in  many  cases 
resembling  those  of  uraemia.  It  seems  probable  that  the 
symptoms  are  dependent  on  the  absorption  of  toxins  from 
the  cavity  of  the  stomach,  just  as  in  some  cases  absorption 
from  a  dilated  stomach  leads  to  tetany.  In  a  case  of  Sir 
William  Broadbent's  (referred  to  in  Dr.  Dreschfeld's  article 
in  Professor  Clifford  Allbutt's  '  System  of  Medicine  ')  8  pints 
of  fluid  were  removed  by  the  sj^phon.  No  sooner,  however, 
was  this  removed  than  the  stomach  began  to  refill  and 
rapidly  regain  its  former  dimensions.  In  the  Leeds  Infirmary 
we  have  had  at  least  four  fatal  cases  of  this  kind,  under  the 
care  of  Dr.  Barrs,  Mr.  T.  R.  Jessop,  Mr.  W.  H.  Brown,  and 


DILATATION  OF  STOMACH  FROM  OTHER  CAUSES    211 

one  of  us  (Mayo  Robson)  respectively.    ]\Ir.  Brown's  case  has 
been  reported  in  the  Lancet  for  October  14,  i8gg,  p.  1017  : 

In  this  case  a  man,  aged  fifty-five  years,  said  to  be  suffering 
from  intestinal  obstruction,  was  admitted  into  the  hospital.  He 
was  in  his  usual  good  health  up  to  forty-eight  hours  previously, 
when  suddenly  he  was  seized  with  intense  pain  in  the  abdomen 
accompanied  by  incessant  vomiting  ;  the  vomiting  continued  until 
three  hours  before  admission.  On  admission  the  hands  were  cold, 
the  pulse  was  small  and  thready,  and  the  face  was  pinched  and 
sunken.  The  abdomen  was  distended  above  the  pubes,  but 
flattened  at  the  sides  and  epigastrium ;  it  was  resonant,  except 
between  the  umbilicus  and  pubes,  where  it  was  dull.  Fluctuation 
could  be  felt,  and  a  succussion  splash  was  obtained.  The  tem- 
perature was  subnormal.  Earlier  in  the  day  the  bowels  had  been 
moved  slightly,  but  no  urine  had  been  passed  since  the  onset  of 
the  illness — i.e.,  for  forty-eight  hours.  The  abdomen  was  not 
tender,  but  the  patient  was  in  great  pain,  turning  from  side  to 
side  constantly,  and  asking  for  relief  from  his  agony.  A  catheter 
was  passed,  and  about  a  drachm  of  bloody  urine  was  withdrawn. 
An  exploring  syringe  was  passed  into  the  fluctuating  swelling 
midway  between  the  umbilicus  and  pubes,  and  withdrew  about 
2  drachms  of  thick  greenish  fluid,  with  a  curious  smell  recalling 
the  contents  of  a  pancreatic  cyst.  As  the  general  aspect  of  the 
case  presented  unusual  difficulties  with  regard  to  diagnosis,  and 
as  it  seemed  certain  that  the  man  would  die  shortly  if  unrelieved, 
and  that  the  pressure  of  the  fluctuating  tumour  was  the  cause  of 
his  suffering,  Mr.  Brown  decided  to  operate.  Ether  was  given, 
and  the  abdomen  was  rapidly  opened  over  the  most  prominent 
part  of  the  swelling.  A  tense,  thin-walled,  rounded  cyst  was 
found,  which  contained  a  dark  liquid  with  some  gas.  As  no  colon 
could  be  seen  or  felt,  and  as  the  tissues  of  the  cyst  wall  seemed  to 
be  more  like  peritoneum  than  any  viscus,  Mr.  Brown  drew  it  to 
the  surface,  opened  it,  and  let  out  about  3  pints  of  dark-green 
viscid  fluid  closely  resembling  that  of  a  pancreatic  cyst.  The 
walls  were  stitched  to  the  skin,  and  the  wound  was  closed.  The 
patient  rallied  from  the  operation,  and  expressed  himself  as  being 
relieved,  but  he  died  five  hours  later.  At  the  necropsy  the  cyst 
was  found  to  be  a  dilated  stomach,  which  would  easily  hold 
5  pints ;  there  was  no  pyloric  obstruction.  The  kidneys  showed 
marked  signs  of  nephritis,  and  were  saccular;  all  the  other  organs 
were  healthy. 

Mr.  Jessop  reported  his  case  before  the  Leeds  and  West 

14 — 2 


212  SURGERY  OF  THE  STOMACH 

Riding  Medico-Chirurgical  Society.  It  also  ended  fatally- 
after  gastrostomy. 

Our  own  case  came  on  ten  days  after  a  duodeno-chole- 
dochotomy  for  the  removal  of  a  gall-stone  impacted  in  the 
common  duct ;  the  patient  was  doing  well  in  every  respect 
until  twenty-four  hours  before  her  death,  when  she  suddenly 
began  to  vomit,  the  abdomen  became  enormously  distended, 
the  urine  became  suppressed,  and  the  patient  died  in  a  state 
of  collapse.  At  the  post-mortem  examination,  beyond  dilata- 
tion of  the  stomach,  nothing  was  found  to  account  for  death. 
It  is  interesting  that  in  this  case  there  were  adhesions  of  the 
pylorus  to  the  liver  and  gall-bladder,  which  we  thought  might 
probably  have  been  the  cause  of  the  trouble.  We  were, 
unfortunately,  out  of  town  at  the  time  of  the  catastrophe ; 
otherwise  we  would  certainly  have  operated,  though  probably 
the  result  would  have  been  the  same,  for  when  the  gravity  of 
the  condition  was  recognised,  and  a  colleague  was  called  in 
to  see  the  patient,  she  was  pulseless  and  cyanosed. 

Dr.  Appel  {Philadelphia  Medical  Journal,  August  12,  i8gg) 
has  reported  a  case  where  acute  dilatation  of  the  stomach 
supervened  on  an  abdominal  injury.  The  abdomen  was 
opened  for  what  was  supposed  to  be  intestinal  obstruction, 
but  three-quarters  of  the  abdominal  cavity  w^ere  occupied  by 
a  dilated  stomach.  The  stomach  was  opened,  giving  vent  to  a 
quantity  of  gas  and  fluid,  the  incision  being  afterwards  closed, 
but  the  second  night  after  the  operation  the  abdomen  became 
distended  as  before,  and  death  rapidly  ensued.  At  the 
necropsy  nothing  was  found  abnormal  except  the  distended 
and  dilated  stomach.  It  was  suspected  that  the  great  sym- 
pathetic abdominal  ganglia  might  have  been  injured,  but 
nothing  was  found  wrong  with  them  on  examination.  Fenger 
{Clinical  Review,  February,  i8g8)  reports  a  case  of  acute  dis- 
tension of  the  stomach  five  days  after  cholecystotomy.  The 
stomach-tube  was  used,  giving  temporary  relief,  but  the 
patient  died  on  the  tenth  day — that  is,  five  days  after  super- 
vention of  the  stomach  symptoms.  The  necropsy  showed 
nothing  amiss  except  an  enormously  dilated  stomach.  Dr. 
Box  and  Mr.  Wallace  {Lancet,  June  4,  1898,  p.  1538)  report 
a   case    in    a   boy,    sixteen    years    of    age,    following   on   a 


DILATATION  OF  STOMACH  FROM  OTHER  CAUSES    213 

blow  on  the  epigastrium.  Abdominal  section  disclosed  a 
dilated  stomach,  which  was  incised  and  emptied,  but  in 
that  case  also  death  followed.  Kirch  {Deutsche  Medicinische 
Wochenschrift,  igoo)  reports  a  case  in  a  youth,  nineteen  years 
of  age,  who  made  a  supper  of  soup  and  beer,  which  was 
followed  by  pain  and  uncontrollable  vomiting.  The  stomach 
was  washed  out,  and  5I  pints  of  grayish-green  fluid  was 
evacuated.  The  next  day  another  2^  pints  were  removed  by  the 
stomach-tube,  but  the  patient  died  in  the  evening  from  heart 
failure,  four  and  a  half  days  after  the  beginning  of  his  illness. 
At  the  post-mortem  examination  the  stomach  was  found  to 
have  lost  its  normal  shape,  and  to  have  the  form  of  a  long 
dilated  tube  reaching  from  the  left  hypochondrium  to  the 
true  pelvis,  and  then  turning  sharply  upwards  to  the 
abdomen. 

Wiesinger  {Deutsche  Medicinische  Wochenschrift,  February, 
1901,  and  Philadelphia  Medical  Journal,  March,  1901)  has 
related  a  case  of  acute  dilatation  of  the  stomach  in  which 
mechanical  blocking  of  the  orifices  of  the  viscus  by  rotation 
seemed  to  be  responsible  for  the  distension. 

The  case  occurred  in  a  man  of  forty-one,  who  was  taken  ill 
immediately  after  a  diabetic  indiscretion,  with  the  clinical  ap- 
pearances of  intestinal  obstruction  associated  with  enormous 
distension  of  the  epigastrium  and  left  hypochondrium.  There 
were  attempts  at  vomiting,  but  nothing  was  brought  forth.  The 
distension  increased,  and  operation  was  undertaken  on  the  fourth 
day  while  the  patient  was  in  extremely  bad  condition.  The  large 
mass  in  the  epigastrium  proved  to  be  the  stomach.  It  was  sus- 
pected at  first  that  this  was  merely  pressed  forward  by  a  cyst 
(possibly  pancreatic)  lying  behind  the  stomach,  as  the  mass  felt 
like  a  cyst.  The  stomach  was  punctured  and  the  contents  drawn 
off,  and  it  was  found  that  the  whole  mass  consisted  of  the  tensely 
distended  stomach.  The  pancreas  itself  was  found  to  be  normal, 
excepting  for  perhaps  some  enlargement.  There  were  widespread 
areas  of  fat  necrosis.  The  stomach  was  found  twisted  at  an  angle 
of  about  180°,  and  fixed  in  this  position.  The  cardia  and  pylorus 
were  completely  closed.  The  patient  recovered  completely,  and 
had  subsequently  no  digestive  disturbances. 

The  case  was  notable  for  the  complete  cure  of  the  fat 
necrosis.     The  latter  condition  was  probably  due  to  pressure 


214  SURGERY  OF  THE  STOMACH 

upon  the  pancreas  by  the  enormously  distended  stomach. 
The  occurrence  of  volvulus  of  the  stomach  was  attributed  to 
the  displacement  of  the  colon  above  the  stomach  resulting 
from  the  abnormal  length  of  the  mesocolon.  After  a  partial 
volvulus  had  occurred,  this  was  increased  by  the  enormous 
secretion  which  took  place  in  the  stomach. 

A  careful  analysis  of  all  the  recorded  cases  of  acute  dilata- 
tion would  seem  to  point  to  a  neuroparesis,  probabl}^  asso- 
ciated with  spasm  of  the  pylorus,  but  so  far  surgery  seems  to 
have  been  of  little  avail  in  these  cases,  and  no  treatment 
seems  to  have  been  of  material  service. 

Nevertheless,  we  must  not  give  up  our  efforts,  and  we 
would  suggest  that  in  every  case  of  this  kmd,  where  stomach 
lavage  has  failed,  but  only  then  (for  the  stomach-tube  is  the 
first  indication,  no  matter  at  what  stage  it  may  be  recognised, 
unless,  indeed,  the  patient  be  actually  dying),  the  abdomen 
should  be  opened,  and  the  stomach  emptied  and  connected 
with  the  jejunum,  thus  providing  for  continuous  drainage 
into  the  intestine.  We  believe  that  as  yet  this  method  has 
not  been  put  to  the  test. 

Although  in  the  greater  number  of  cases  of  stenosis  of  the 
pylorus  requiring  surgical  treatment  a  general  ansesthetic 
may  be  given,  it  is  well  to  bear  in  mind  that,  if  necessary,  as 
in  serious  cases  like  those  under  consideration,  the  operation 
of  gastro-enterostomy  may  be  performed  under  local  anees- 
thesia  produced  by  Schleich's  method.  Herczel  has  reported 
two  cases  where  he  did  gastro-enterostomy  in  this  way,  in 
both  of  which  recovery  was  rapid.  In  another  case  which  he 
did  under  a  general  anaesthetic  pneumonia  supervened,  and 
he  believed  that  the  anesthetic  played  a  prominent  part  in 
its  production.  Czerny  has  remarked  that  a  certain  number 
of  patients  submitted  to  stomach  operations  suffer  from 
pneumonia,  owing  to  the  predisposition  caused  by  the  cessa- 
tion of  abdominal  respiration  and  the  superficial  character  of 
the  thoracic  respiration,  on  account  of  the  pain  in  the  wound 
caused  by  costal  movement.  We  have  on  several  occasions 
performed  operation  of  the  stomach  successfully  under  cocaine, 
where  we  thought  the  patient  too  feeble  for  general  anses- 
thesia,  or  where  chest  complications  rendered  chloroform  or 


DILATATION  OF  STOMACH  FROM  OTHER  CAUSES  215 

ether  inadvisable,  and  with  very  httle  pain,  discomfort,  or 
shock  to  the  patient. 

The  accompanying  drawing  is  taken  from  a  case  under  the 
care  of  our  colleague  Dr.  Barrs.  The  patient  was  ill  with 
ulcerative  endocarditis,  and  suddenly  developed  enormous 
abdominal  distension,  which  proved  rapidly  fatal.  There 
had  been  no  previous  stomach  symptoms,  and  at  the  autopsy 
nothing  was  discovered  to  account  for  the  condition. 

But  that  the  condition  of  acute  gastric  dilatation  is  not 
hopeless  the  following  cases  distinctly  prove  : 

In  one,  a  woman  of  thirty-five  (under  the  care  of  one  of  us^ 
A.  W.  M.  R.),  recoA-ering  smoothly  from  cholecystotomy,  which 
had  been  performed  a  week  previously,  was  suddenly  seized  with 
pain  in  the  epigastrium,  followed  by  vomiting,  which  soon  became 
ineffectual  in  emptying  the  stomach.  Rapid  dilatation  ensued, 
and  the  stomach  not  only  formed  a  large  swelling,  filling  up  the 
superior  abdominal  region,  but  also  extended  well  below  the 
umbilicus  towards  the  pubes.  This,  owing  to  pressure  on  the 
diaphragm,  and  through  it  to  pressure  on  the  heart  and  lungs,  led 
to  great  shock,  quick  and  oppressed  breathing,  and  a  rapid,  feeble 
pulse,  with  signs  of  .lividity  and  imperfect  blood  aeration.  The 
urine  was  scanty,  and,  in  fact,  almost  suppressed. 

Strychnine  was  freely  given  subcutaneously,  but  no  relief  came 
until  the  stomach-tube  was  used,  when  a  large  quantity  of  gas 
and  several  pints  of  brownish  fluid  were  evacuated ;  the  lavage 
was  repeated  several  times  during  the  next  two  days,  during  which 
time  alimentation  was  entirely  rectal.  It  was  interesting  to  note 
that  the  pulse  and  temperature  were  paradoxical,  the  former 
running  up  to  150  and  the  latter  down  to  97'3.  All  the  symptoms 
passed  off  under  treatment  almost  as  quickly  as  they  came,  and  in 
a  week  the  stomach  had  returned  to  the  normal  size. 

In  another  case,  a  lady  of  twenty-nine,  who  had  had  abdominal 
hysterectomy  for  a  large  myoma,  and  whose  after-progress  had 
been  most  satisfactory,  the  w^ound  having  healed  by  first  intention, 
and  the  temperature  and  pulse  having  been  normal  throughout, 
was  seized  with  pain  over  the  stomach  a  fortnight  after  opera- 
tion; this  was  followed  by  vomiting  of  frothy  mucus  with  a  few 
brownish  streaks  in  it,  and  by  distension  of  the  abdomen,  begin- 
ning in  the  epigastrium.  On  percussion  the  stomach  was  found 
to  be  down  to  the  pubes,  and  on  succussion  a  well-marked  splash 
was  easily  obtained ;  the  pulse  became  rapid  and  the  face  pinched, 
so  that  within  thirty-six  hours  of  being  quite  well  the.  patient 
presented  every  appearance  of  impending  death.     The  urine  was 


2i6  SURGERY  OF  THE  STOMACH 

very  much  diminished,  and  for  twenty-fovir  hours  almost  sup- 
pressed. Strychnine  was  given  subcutaneously  and  rectal  feeding 
was  adopted,  but  no  relief  was  obtained  until  the  stomach  was 
washed  out,  after  which  relief  was  immediate  and  the  patient 
steadily  improved,  though  no  food  was  given  by  the  mouth  for 
three  days.  Within  a  week  the  stomach  had  returned  to  the 
normal  size.  Here  also  the  temperature  and  pulse  were  para- 
doxical, the  former  being  subnormal  and  the  latter  very  rapid. 
The  only  cause  that  could  be  assigned  was  the  eating  of  a  raw 
apple,  but  that  may  have  had  nothing  to  do  with  the  condition. 
The  patient  said  that  she  had  always  been  subject  to  a  weak 
digestion  since  childhood,  but  at  the  time  of  operation  nothing 
abnormal  was  noticed  in  the  stomach. 

It  seems  not  improbable  that  some  of  the  cases  of  ileus 
after  abdominal  operations  may  be  caused  by  acute  dilatation 
of  the  stomach,  which,  when  once  initiated,  tends  to  persist 
and  get  worse,  owing  to  the  distended  stomach  dragging  on 
and  kinking  the  duodenum,  thus  leading  to  shock  by  pressure 
on  the  heart,  without  there  being  any  sign  of  sepsis.  Hence, 
in  all  cases  of  ileus  after  operation  the  use  of  the  stomach- 
tube  should  not  be  neglected. 

Acute  post-operative  dilatation  of  the  stomach  is  said  by 
P.  Miller  {Deutsche  Zeitschrift  filr  Chirtirgie,  August,  igoo)  to 
be  frequently  due  to  compression  of  the  duodenum  by  the 
superior  mesenteric  artery.  He  thinks  that  in  the  majority 
of  such  cases  recovery  occurs  either  spontaneously  or  as  the 
result  of  stomach  lavage.  Where  death  occurs  in  such  cases, 
Miller  thinks  that  the  fatal  result  is  frequently  attributed  to 
peritonitis,  whereas  in  truth  it  is  due  to  the  above  form  of 
intestinal  obstruction.  Some  of  the  later  cases  we  have 
described  should  possibly  come  under  this  form.  If  Miller's 
explanation  be  correct,  the  cause  of  the  dilatation  may  be 
removed  by  rolling  the  patient  over  into  the  prone  position. 
This  measure  was  practised  with  success  in  the  following 
case : 

M.  P.,  woman,  aged  fifty-eight,  was  sent  to  one  of  us 
(B.  G.  A.  M.)  by  Dr.  J.  Ellison  suffering  from  a  large  abdominal 
tumour,  which  proved  to  be  a  parovarian  cyst.  After  operation 
matters  progressed  smoothly  for  twenty  hours ;  then  vomiting  set 
in,  and  the  stomach  was  found  to  be  much  distended,  producing  a 


DILATATION  OF  STOMACH  FROM  OTHER  CAUSES   217 

prominent  bulging  in  the  epigastric  and  umbilical  regions,  which 
contrasted  very  strikingly  with  the  emptiness  of  the  rest  of  the 
abdomen.  The  patient  was  rolled  over  on  to  her  face,  vomited 
three  times  within  half  an  hour,  the  quantity  on  each  occasion 
being  over  a  pint,  but  almost  immediately  expressed  herself  as 
relieved.  Vomiting  ceased  and  did  not  recur,  and  the  patient  made 
a  good  recovery. 

It  is  not  improbable  that  the  intestines,  supported  by  the 
tumour,  dragged  downwards  after  their  support  was  gone, 
and  thus  caused  the  superior  mesenteric  artery  to  constrict 
the  duodenum.  With  the  patient  in  the  prone  position  such 
a  cause  would  be  removed. . 

Atonic  Dilatation  of  the  Stomach. 

Dilatation  from  Atony  is  due  to  various  general  and  local 
causes,  and  may  persist  after  the  original  cause  has  disap- 
peared. As  we  mentioned  when  speaking  of  dilatation  of 
the  stomach  generally,  pure  atonic  dilatation,  apart  from 
some  degree  of  stenosis  or  some  mechanical  cause,  is 
probably  rare.  The  condition  is  due  to  a  weakened  state 
of  the  muscular  coats  of  the  stomach,  so  that  there  is 
deficient  peristalsis,  and  the  contents  are  not  pushed  towards 
the  pylorus  sufficiently  rapidly  for  the  stomach  to  empty 
itself  in  a  normal  time. 

In  these  cases,  even  in  the  morning  before  breakfast  has 
been  taken,  a  stomach  splash  may  be  obtained  on  succussion, 
and  if  the  contents  be  siphoned  off,  particles  of  food,  with 
fluid,  will  be  found — not  necessarily  coarse  particles  of  food, 
as  are  found  in  dilatation  due  to  true  stenosis  of  the  pylorus, 
but  digested  food  that  would  easily  pass  the  pylorus  if 
normal  peristalsis  were  present. 

Symptoms. 

The  appetite  is  poor  as  a  rule,  though  it  may  be  abnor- 
mally increased.  Thirst  is  increased,  and  there  is  a  feeling 
of  dryness  in  the  throat  almost  constantly  present.  Flatu- 
lency, relieved  by  eructations,  is  usually  met  with,  and  the 
expelled  gas  may  have  an  unpleasant  or  disagreeable  odour 
There  is  a  constant  sense  of  oppression,  with  fulness  at  the 


2i8  SURGERY  OF  THE  STOMACH 

epigastrium,  and  frequently  palpitation  will  be  complained 
of.  Vomiting  occurs  in  advanced  cases,  and  may  be  repeated 
dail}'  or  once  or  twice  a  week,  the  vomited  matters  being 
offensive,  and  containing  yeast  cells,  sarcinge,  and  other 
organisms.  Free  HCl  will  usually  be  found.  Emaciation 
is  usually  present,  and  as  the  disease  advances  it  may  become 
extreme. 

There  are  certain  cases  of  dilated  stomach  of  the  atonic 
variety  in  which  the  chief  symptoms  depend  on  the  great 
bulk  of  the  organ.  As  descriptive  of  the  amount  of  paralytic 
distension  that  is  possible,  Bamberger  mentions  an  extreme 
case,  in  which  the  stomach  held  70  pints  of  fluid  (Gould 
and  Pyke,  p.  630).  As  these  cases  are  frequently  dependent 
on  chronic  catarrh  or  on  some  general  cause  not  mechanical, 
it  is  not  necessary  in  a  surgical  work  to  enter  very  fully  into 
the  etiology,  except  to  say  that  the  myasthenic  variety  of 
dilatation  may  be  dependent  on  {a)  fatty  or  colloid  degenera- 
tion of  muscle,  {h)  destruction  of  muscle  fibres  by  ingested 
poisons,  by  ulceration,  fibrosis,  and  cancer,  and  on  (c)  paresis 
of  the  nerves  of  the  stomach. 

General  and  medical  treatment,  supplemented,  if  need  be, 
by  electrical  treatment  and  lavage,  if  carried  out  syste- 
matically and  for  a  sufficient  length  of  time,  usually  yield 
good  results ;  but  in  some  cases,  despite  regular  lavage 
of  the  dilated  organ,  well-regulated  diet,  and  general  medical 
treatment,  the  dilatation  persists,  and  the  nutrition  of  the 
patient  and  the  general  health  become  seriously  impaired. 
In  such  cases  the  operation  of  gastrorrhaphy  or  gastroplica- 
tion  may  be  worth  considering. 

Gastroplication. 

Bircher  performed  the  operation,  and  reported  three  cases 
in  1890,  and  Weir  of  New  York  published  a  paper  on  this 
subject  in  1892.  The  reports  show  that  the  operation  is 
a  most  beneficial  one  if  the  cases  be  well  selected ;  but 
before  performing  gastroplication  it  should  be  clearly  ascer- 
tained that  there  is  no  mechanical  obstruction,  either  at  the 
pyloric  orifice  or  in  the  duodenum. 

The  following  diagrams  illustrate  the  method  of  folding 


DILATATION  OF  STOMACH  FROM  OTHER  CAUSES   219 

and  diminishing  the  volume  of  the  stomach  adopted  by 
various  operators.  In  the  sHghter  cases,  probably,  Bircher's 
operation  would  do  all  that  is  required,  but  in  the  more 
severe  cases  a  method  first  described  by  one  of  us  (B.  G.  A.  M., 
Lancet,  i8g8)  is  the  more  efficient.     The  operation  is  neither 


Fig,  45. — Gastroplication. 


difficult  nor  attended  with  serious  risk,  since  there  is  no 
danger  of  sepsis,  as  the  cavity  of  the  stomach  is  not  opened ; 
and  as  the  stomach  can  be  drawn  out  of  the  wound  to  be 
sutured,  the  general  peritoneal  cavity  is  saved  from  long 
exposure. 

In  the  Hunterian  Lectures  we  collected  all  the  reported 
cases,  twenty-eight  in  number,  showing  a  7*1  per  cent, 
mortality. 


SURGERY  OF  THE  STOMACH 


We  have  only  seen  two  cases,  in  addition  to  the  one 
referred  to,  that  we  thought  suitable  for  gastroplication. 

One  patient,  W.  R.,  aged  thirty-five  years,  who  had  been 
invalided  for  eighteen  months,  but  who  had  had  stomach  symp- 
toms for  seven  years,  and  who  had  tried  lavage  and  other  medical 
treatment  for  several  years  without  benefit,  expresses  himself  as 


Fig.  46.— Gastroplication.     (Moynihan's  Method.) 

cured  of  all  his  former  symptoms,  and  he  certainly  looks  well, 
and  seems  able  to  take  his  food  without  any  difficulty.  The 
operation  was  performed  on  January  24,  1900,  by  Mayo  Robson, 
after  the  plan  first  carried  out  by  Moynihan,  and  at  the  same 
time  the  pylorus,  which  was  thought  to  be  narrow,  was  stretched 
by  invaginating  the  anterior  wall  of  the  stomach,  and  pressing 
first  the  index,  then  the  middle  finger,  then  the  thumb,  and 
lastly  two  fingers,  through  it,  until  a  freely  patent  channel  was 
obtained. 


DILATATION  OF  STOMACH  FROM  OTHER  CAUSES  221 

In  another  case,  a  Mrs.  R.,  aged  fifty-six,  was  sent  to  one  of  us 
(A.  W.  M.  R.)  by  Dr.  West  of  Morley,  with  an  enormously 
dilated  stomach,  reaching  about  to  the  pubes,  and  with  a  history 
of  stomach  symptoms  extending  over  several  years.  Recently 
she  had  been  entirely  confined  to  bed,  had  lost  all  desire  for 
food,  and  had  become  much  emaciated.  Gastroplasty  and  dila- 
tation of  the  pylorus  by  Hahn's  method  were  performed  on 
April  23,  igoo,  with  immediately  brilliant  results,  and  in  two 
months  the  patient  had  gained  over  a  stone  in  weight. 

The  after-history  of  this  case  is  both  interesting  and  important ; 
for  six  months  later,  although  she  could  take  food  and  digest  it 
well,  she  began  to  suffer  from  severe  pain  at  the  epigastrium, 
which,  after  a  full  meal  at  first,  and  later  after  any  solid  food, 
became  so  distressing  that  she  had  to  resort  to  living  on  milk  and 
liquid  foods. 

We  were  again  asked  to  see  her,  and  found  her  in  considerable 
distress  from  pain  at  the  epigastrium,  associated  with  great 
tenderness,  rigid  section,  and  an  obscure  feeling  of  swelling, 
as  if  a  tumour  were  present.  On  distending  the  stomach  with 
COg,  it  reached  an  inch  below  the  umbilicus. 

Vomiting  occurred  at  times,  but  was  not  a  marked  symptom. 
She  weighed  a  stone  more  than  when  she  was  operated  on, 
though  Dr.  West  and  her  friends  said  that  she  had  lost  weight 
considerably  since  the  pain  began. 

Lavage  of  the  stomach,  rest,  and  dieting  giving  no  relief,  it 
was  decided  to  perform  gastro-enterostomy,  which  was  done  on 
December  5,  1900. 

On  opening  the  abdomen,  very  extensive  adhesions  were  found, 
clearly  following  on  the  gastroplication,  as  the  anterior  wall  of  the 
stomach,  especially  towards  and  at  the  pyloric  end,  was  fixed  to 
the  liver  and  to  the  abdominal  wall ;  and  it  was  at  this  part  where 
her  pain  had  always  been  before,  and  where  the  tenderness  was 
constantly  felt.  The  gastroplication  had  produced  the  condition 
shown  in  the  diagram,  obliteration  of  the  anterior  wall,  the 
greater  and  lesser  curvatures  being  close  together ;  but  the 
posterior  wall  had  remained  stretched,  and  was  only  limited 
by  the  capacity  of  the  lesser  peritoneal  sac,  which  it  filled 
completely. 

The  pylorus  was  quite  patent.  The  adhesions  to  the  abdominal 
wall  were  separated ;  but  as  a  large  raw  surface  was  necessarily 
left,  it  was  felt  that  the  adhesions  would  probably  re-form.  A 
posterior  gastro-enterostomy  was  therefore  done.  Recovery  was 
uneventful,  and  the  patient  left  the  '  home '  within  the  month 
quite  free  from  symptoms  and  feeling  well.  She  could  take 
solids  and  enjoy  her  meals.     The  improvement  has  continued. 


CHAPTER  XIV 

PERIGASTRITIS 

Adhesions  of  the  stomach  and  pylorus  to  neighbouring 
organs  are  a  common  result  of  perigastritis,  the  causes  of 
which  may  be  extrinsic  or  intrinsic.  Among  the  extrinsic 
causes  are  gall-stones,  tuberculous  peritonitis,  local  peri- 
tonitis from  intestinal  ulceration  or  from  malignant  growths 
in  adjoining  organs,  typhoid  fever,  and  possibly  other  fevers. 
Among  the  intrinsic  causes,  ulceration  is  by  far  the  most 
frequent,  though  cancer  and  syphilis  of  the  stomach  must 
also  be  included. 

Though  at  the  time  adhesions  the  result  of  perigastritis 
are  conservative,  and  may  frequently  result  in  the  saving  of 
life  by  limiting  the  peritonitis,  the  result  of  perforation  or  of 
bacterial  infection  due  to  ulcer,  yet  later  such  adhesions 
may  lead  to  great  functional  disturbance  by  interfering  with 
the  motor  activity  of  the  stomach  and  causing  pain,  disability, 
and  other  ailments.  As  we  shall  hope  to  show,  these  dis- 
turbances caused  by  adhesions  may  not  be  merely  of  a 
functional  nature,  producing  dyspepsia  and  so-called  visceral 
neuroses  ;  but  they  may,  and  frequently  do,  cause  dilatation 
of  the  stomach,  vomiting,  severe  pain,  and  great  loss  of 
flesh. 

In  1893  one  of  us  (A.  W.  M.  R.)  read  a  paper  before  the 
Clinical  Society  of  London  on  the  subject  of  pyloric  adhe- 
sions, and  related  several  cases  which  had  been  cured  or 
relieved  of  long-continued  stomach  symptoms  by  their 
division.  This  was,  we  believe,  the  first  time  that  attention 
had  been  drawn  to  the  importance  of  adhesion  around  the 
pylorus  as  a  cause  of  dilatation  of  the  stomach  and  other 


PERIGA  S  IRITIS  223 

digestive  troubles.  Since  that  time  our  experience  on  this 
subject  has  considerably  extended,  and  we  can  now  point  to 
a  very  large  number  of  cases  (over  fifty)  of  pyloric  or  other 
stomach  adhesions,  caused  in  some  cases  by  gall-stones,  in 
others  by  gastric  ulceration,  where  the  adhesions,  though 
not  the  original  disease,  were  of  the  first  importance  in 
producing  the  symptoms  for  which  operation  was  undertaken, 
and  where  gastrolysis  led  to  their  relief  or  cure.  Though  in 
some  cases  the  adhesions  may  be  due  to  a  perforating  ulcer, 
it  is  by  no  means  necessary  that  ulceration  need  be  near 
perforation  to  lead  to  perigastritis ;  for  in  many  cases,  long 
before  the  peritoneum  is  reached  by  the  ulcer,  a  local  peri- 
tonitis occurs,  leading  to  the  pain  and  well-known  local 
tenderness  which  characterize  ulcer  of  the  stomach,  and  then 
lymph  is  thrown  out  which  may  fix  the  inflamed  region  to 
contiguous  organs. 

Adhesions  are  found  around  the  stomach  in  about  5  per 
cent,  of  all  necropsies,  and  about  40  per  cent,  of  all  cases  of 
ulcer  of  the  stomach  are  associated  with  adhesions.  Our 
combined  experience  in  a  very  considerable  number  of  abdo- 
minal sections,  over  700  of  which  have  been  in  the  upper 
abdominal  region,  shows  that  pyloric  adhesions  are  very 
much  more  common  than  is  usually  supposed,  and  that  their 
importance  is  greater  than  is  generally  recognised  even  at 
the  time  of  operation.  This  is  especially  the  case  in  chole- 
lithiasis, where  we  are  accustomed  to  find  gastric  dilatation 
as  a  regular  sequence  of  gall-stones,  and  to  look  for  it  as  an 
ordinary  concomitant  sign  ;  and  in  such  cases  it  is  always  due 
to  adhesions  of  the  pylorus  to  the  gall-bladder  and  liver. 

Sometimes  the  adhesions  may  be  strictly  limited  to  the 
pylorus  and  gall-bladder,  leading  to  a  characteristic  train 
of  symptoms.  In  a  case  under  the  care  of  one  of  us 
(A.  W.  M.  R.),  '  acute  dilatation  '  of  the  stomach  came  on 
suddenly  and  ended  fatally  within  thirty-six  hours,  it  being 
apparently  due  solely  to  pyloric  adhesions,  as  a  post-mortem 
examination  revealed  no  other  cause  (see  Acute  Dilatation). 
At  other  times  adhesions  may  extend  from  the  pylorus  along 
the  lesser  curvature  of  the  stomach,  fixing  the  upper  border 
of  the  stomach  firmly  to  the  gall-bladder,  cystic  duct,  and 


224  SURGERY  OF  THE  STOMACH 

under  surface  of  the  liver.  When  the  pylorus  is  tied  up  in 
this  abnormal  position,  not  only  are  the  natural  movements 
of  the  pylorus  and  stomach  interfered  with,  but  the  food  has 
to  be  forced  out  at  a  higher  level,  and  when  the  pylorus  is 
alone  fixed  a  kink  forms,  leading  soon  to  well-marked  dilata- 
tion with  flatulence,  chronic  dyspepsia,  and  loss  of  flesh. 
Where  perigastritis  is  due  to  ulceration,  the  adhesions  are 
onty  found  over  the  site  of  the  ulcer,  and  if  this  be  at  the 
pylorus  a  double  difficulty  is  presented,  for  not  only  is  there 
fixation  of  the  pylorus  at  an  abnormally  high  level,  but  the 
pyloric  orifice  itself  becomes  stenosed  from  the  contraction 
due  to  the  healing  of  the  ulcer.  If  the  ulcer  happens  to  be 
on  the  anterior  wall  of  the  stomach,  it  may  lead  to  hour-glass 
contraction,  as  in  cases  related  under  that  heading. 

The  symptoms  vary  according  to  the  site  and  cause  of  the 
disease,  from  mere  dyspepsia  to  serious  apepsia,  and  the 
brief  descriptions  of  cases  given  at  the  end  of  this  chapter  are 
selected  as  illustrating  the  different  causes  and  effects  of 
gastric  adhesions. 

Although  cancer  is  a  well-recognised  cause  of  perigastritis 
in  every  region  of  the  stomach,  the  symptoms  from  adhesions 
are  merged  in  the  more  serious  ailment ;  it  is,  therefore, 
unnecessary  that  we  should  further  consider  them  at  this 
moment,  except  to  say  that  they  seriously  add  to  the  diffi- 
culty and  danger  of  pylorectomy  or  partial  gastrectomy. 
The  cases  mentioned  can  leave  no  doubt  in  the  minds  of 
our  readers  as  to  the  serious  effect  of  pyloric  and  gastric 
adhesions,  although  it  is  a  curious  fact  that  many  recognised 
authorities  on  stomach  diseases  barely  mention  them.  The 
remarks  that  were  made  by  several  eminent  physicians  at 
the  reading  of  the  original  paper  on  this  subject  before  the 
Clinical  Society  of  London  showed  that,  although  the  subject 
was  not  unknown,  its  importance  was  certainly  underrated. 
That  we  are  not  exaggerating  its  importance  is  shown  by 
reports  of  cases  by  other  observers.  For  instance,  Hart- 
mann  and  Soupault  {Revue  de  Chirurgie,  1899,  p.  340)  relate 
cases  where  adhesions  were  the  only  apparent  cause  of 
gastric  dilatation.  Terrier,  in  his  work  on  "  Stomach 
Surgery  "  (1899),  relates  a  case  of  a  woman,  aged  sixty-two 


PERIGASTRITIS  :225 

years,  whose  gastric  symptoms  were  relieved  by  breaking 
down  adhesions. 

Bireto  related  a  very  instructive  case,  resembling  one 
above  described,  where  a  band  was  found  attached  to  the 
lesser  curvature  of  the  stomach,  about  j.\  inches  from  the 
pylorus,  which  ran  obliquely  downward  to  the  anterior 
abdominal  wall  on  the  right  of  the  umbilicus.  When  the 
stomach  was  full,  the  band  dragged  the  upper  border  down- 
wards, and  produced  a  kink  which  led  to  stenosis.  A  case 
related  by  Mr.  H.  W.  Page  {British  Medical  Journal, 
January  23,  i8gg)  is  a  good  example,  and  many  others  can 
now  be  found  scattered  through  medical  literature. 

The  diagnosis  in  these  cases  rests  on  a  careful  considera- 
tion of  the  previous  history,  together  with  the  presence  of 
well-marked  signs  and  symptoms,  so  that  it  is  not  generally 
difficult.  There  will  usually  be  a  history  of  gall-stones, 
typhoid  fever,  ulcer  of  the  pylorus,  or  some  local  peritonitis 
in  the  pyloric  region,  months  or  years  previously.  This  will 
have  been  followed  by  indefinite  dyspepsia  and  flatulence, 
which  later  takes  a  very  definite  shape,  consisting  of  dis- 
comfort and  pain  after  food,  especially  after  a  full  meal,  so 
that  the  patient  prefers  to  take  several  small  repasts  rather 
than  one  or  two  large  meals.  The  pain  and  discomfort  are 
at  once  relieved  by  the  recumbent  posture,  so  that  a  necessity 
to  lie  down  or  rest  after  every  meal  is  suggestive.  Relief  is 
frequently  found  by  the  wearing  of  a  belt,  and  this  is  usually 
discovered  by  the  patient  before  advice  is  sought.  The  pain 
is  often  of  a  dragging  character.  At  times  it  may  be  acute, 
and  it  is  increased  or  brought  on  by  lifting  or  reaching,  say, 
to  adjust  a  picture.  Walking  or  any  active  exertion  is 
shunned,  and  inability  to  perform  ordinary  duties  is  com- 
plained of.  When  dilatation  of  the  stomach  is  well  marked 
there  ma}'  be  loss  of  flesh  and  vomiting  every  few  days,  often 
in  large  quantity. 

Besides  the  ordinary  signs  of  dilatation  of  the  stomach  and 
the  tenderness  between  the  umbilicus  and  the  ninth  costal 
cartilage,  as  shown  by  the  rigid  right  rectus,  there  is  an 
important  physical  sign  to  be  obtained  by  distending  the 
stomach  with  gas,  when,  in  case    of  pyloric  adhesions,  the 

15 


226  SURGERY  OF  TEE  STOMACH 

cavity  of  the  stomach  will  be  found  to  extend  further  to  the 
right  and  higher  than  normal.  An  entire  cessation  of  pain 
and  freedom  from  dyspeptic  troubles  if  the  patient  be  con- 
fined to  bed  is  suggestive,  for  it  will  be  seen  that  under  these 
circumstances  the  higher  level  of  the  pylorus  is  done  away 
with,  and  the  recumbent  posture  prevents  the  dragging  of 
adhesions ;  but,  after  all,  an  exploratory  operation  is  the 
only  way  of  setting  doubt  at  rest,  and  if  these  distressing 
symptoms  have  resisted  long-continued  medical  treatment 
a  surgical  operation  is  clearly  justifiable,  though  doubtless 
in  some  of  the  less  severe  forms  careful  medical  treatment 
may  lead  to  an  amelioration  of  symptoms,  and  may  give 
such  marked  relief  that  an  operation  will  not  be  called  for. 
Relief  may  be  obtained  by  advising  the  patient  to  take  small 
meals,  to  avoid  bulky  and  fermentable  foods  such  as  potatoes 
and  bread,  to  rest  after  meals,  and  to  wear  a  well-fitting 
abdominal  belt. 

In  some  cases  where  relief  ensues  without  operation,  it  is 
probably  due  to  the  stretching  of  adhesions  and  to  their 
absorption,  if  the  exciting  cause  has  fortunately  been  re- 
moved ;  but  in  the  more  severe  cases,  where  the  adhesions 
are  almost  universal,  such  a  fortunate  termination  of  symp- 
toms is  scarcely  to  be  hoped  for,  and  in  some  cases  the 
adhesions  are  so  extreme  that  nothing  short  of  gastro- 
enterostomy can  prove  of  any  avail. 

Gastric  adhesions  may  give  rise  to  no  symptoms,  but 
usually  they  interfere  with  the  motor  functions  of  the 
stomach.  Adhesions  may  be  suspected  (a)  when  there  is  a 
widespread  tenderness  in  the  epigastrium,  extending  beyond 
the  stomach  area,  and  associated  with  rigidity  of  both  recti ; 
{h)  when  lavage  and  other  treatment  fail  to  relieve  the  defi- 
cient motor  functions  ;  and  (c)  when  after  treatment  for 
gastric  ulcer  the  pain  and  tenderness  persist. 

Gastrolysis. 

We  have  heard  it  asked,  '  What  is  the  use  of  simply 
detaching  adhesions  ?'  Fortunately,  our  experience  in  this 
class  of  cases  is  sufficient  for  us  to  give  a  very  direct  answer 
to  this  query,  for  we  can  point  to  many  cases  of  cure  where 


PERIGASTRITIS  227 

men  and  women,  formerly  invalided  by  pain  and  dyspepsia, 
are  now  leading  active  and  useful  lives.  Slight  adhesions 
we  are  accustomed  to  separate  with  the  fingers,  firmer  bands 
to  divide  between  ligatures,  going  carefully  to  work  until  the 
pylorus  is  quite  free.  Where  the  omentum  is  available,  we 
usually  bring  the  right  border  upwards,  and  leave  it  between 
the  pylorus  and  the  gall-bladder  and  the  liver,  so  that,  should 
any  adhesions  form  again,  they  will  be  in  the  form  of  a 
loose  mesentery,  and  not  binding,  like  adhesions  to  fixed 
organs. 

The  operation  of  gastrolysis,  where  adhesions  are  solely 
responsible  for  the  stomach  trouble,  is  a  perfectly  safe  one, 
and  in  a  large  series  of  operations  we  have  had  no  fatality. 
In  the  Hunterian  Lectures  we  collected  from  all  sources 
"]"]  operations,  the  rate  of  mortality  being  2*5  per  cent.  Of 
these,  47  were  personal  cases  without  a  death. 

Wherever  the  adhesions  are  very  firm,  and  especially 
where  they  are  extending  over  a  wide  area,  great  care  must 
be  exercised  in  separating  them,  and  when  separated,  in 
examining  the  stomach  carefully  to  see  if  there  is  a  fistula 
left,  for  in  no  less  than  seven  cases  we  have  had  to  close 
perforations  under  such  circumstances  ;  and,  in  several  of 
them  there  was  a  clear  history  of  perforation  of  gastric  ulcer, 
with  subsequent  recovery,  though  the  symptoms  of  ulceration 
had  persisted  and  necessitated  operative  treatment. 

A  case  of  stomach  and  gall-bladder  fistula  (seen  by  Mayo 
Robson)  in  a  lady  of  fifty-four,  due  to  perigastritis  of  extrinsic 
origin,  is  described  in  the  chapter  on  Fistula.  When  the 
adhesions  were  separated  there  was  a  passage  into  the 
stomach  readily  admitting  a  No.  6  catheter,  which  was 
easily  closed  by  a  purse-string  suture,  the  gall-bladder  open- 
ing being  used  for  drainage,  the  patient  making  a  good 
recovery. 

In  another  case,  that  of  a  middle-aged  lady,  seen  by 
Mayo  Robson,  with  Dr.  Johnstone  of  Ilkley,  on  separating 
the  pylorus  from  the  liver,  an  opening  was  found  the  size 
of  a  threepenny-piece  leading  into  the  stomach,  the  base  of 
the  ulcer  being  formed  by  indurated  liver  tissue.  The  case 
is  more  fully  described  under  Pyloroplasty. 

15—2 


228  SURGERY  OF  THE  STOMACH 

Curiously,  on  one  day  while  operating  at  the  Leeds 
Infirmary,  one  of  us  (A.  W.  M.  R.)  had  two  consecutive 
cases  where  recovery  from  perforation  had  occurred,  leaving 
very  firm  adhesions.  In  one  case,  that  of  a  middle-aged 
man,  a  patient  of  Dr.  Robinson's  of  Low  Moor,  there  were 
very  firm  adhesions  of  the  pylorus  to  surrounding  organs 
and  to  the  omentum,  and  on  separating  the  latter  in  order  to 
perform  pyloroplasty  the  round  opening  of  a  perforation  was 
quite  distinct.  Dr.  Robinson  said  that  he  recollected  the 
date  of  the  accident  several  months  previously,  and  that  he 
had  prepared  the  patient  for  operation  then,  but  under  rest, 
opium,  and  abstention  from  food,  he  recovered.  The  ulcer 
was  excised  and  pyloroplasty  performed,  the  patient  making 
a  very  good  recovery.  The  next  case  was  one  of  hour-glass 
contraction  due  to  chronic  ulcer,  and  here  the  history  of 
perforation  was  also  distinct,  the  patient  at  the  time  having 
been  treated  by  rectal  feeding  for  a  week  and  being  kept  in 
bed  for  a  month.  Excision  of  the  ulcer  and  posterior  gastro- 
enterostomy was  followed  by  recovery. 

In  another  case  (also  under  the  care  of  Mayo  Robson),  of 
a  middle-aged  woman,  a  very  firm  adhesion  to  the  anterior 
abdominal  wall  was  evidently  the  site  of  a  perforation,  the 
history  of  which  was  very  clear,  and  suspected  by  her 
medical  man  at  the  time,  though  the  patient  recovered.  On 
separating  the  adhesions  there  was  an  opening  admitting  a 
No.  5  catheter  leading  into  the  stomach.  It  was  readily 
closed  by  inversion  of  the  edges  and  the  use  of  a  purse- 
string  suture. 

We  have  in  the  same  way  found  adhesions  to  the  large 
and  small  intestine  and  pancreas  and  the  diaphragm. 

The  lesson  to  be  learnt  is  that  due  care  must  be  taken  in 
separating  firm  adhesions,  and  the  parts  must  also  be  care- 
fully examined  subsequently,  not  onl}^  for  the  arrest  of 
haemorrhage,  but  also  to  see  that  there  is  no  fistula  left. 

Where  gastric  adhesions  the  result  of  perigastritis  are 
present  and  not  producing  symptoms,  being  only  discovered 
accidentally  during  the  performance  of  other  operations,  we 
would  not  always  counsel  their  division  unless  it  can  be 
readily  done,  since  they  undoubtedly  do  exist  at  times  with- 


PERIGASTRITIS  229 

out  serious  detriment  to  the  patient.  If  the  pylorus  is 
patent,  yet  embarrassed  by  adhesions,  we  always  separate 
them,  and  try  to  avoid  their  recurrence  by  interposing  the 
right  free  border  of  the  omentum  between  the  raw  surfaces 
left  by  the  gastrolysis,  thus  substituting  a  long,  freely- 
movable  attachment  for  short,  binding  ligaments,  should 
adhesions  re-form.  If,  however,  adhesions  are  very  exten- 
sive, very  short,  dense,  and  firm,  the  operation  of  posterior 
gastro-enterostomy  had  better  be  done,  as  in  some  of  the 
cases  related  below,  and  this  especiall}'  if  at  the  same  time 
there  is  stenosis  of  the  pylorus  or  an  hour-glass  stomach. 

M.  Merklen  {SocieVe  Medicale  des  Hopitaux,  Paris,  January, 
1899)  related  the  case  of  a  man,  aged  forty,  who,  having  had  for 
three  weeks  crises  of  epigastric  pain  which  radiated  into  the  retro- 
sternal, and  even  submaxillary,  regions,  was  on  November  10, 
1896,  suddenly  seized  with  acute  pain  in  the  left  flank  and  all  the 
signs  of  gastric  perforation.  The  peritonitis  was  limited  by 
previous  adhesions,  and  a  subphrenic  gaseous  abscess  formed. 
On  December  2  nearly  a  litre  of  pus  was  evacuated.  The  patient 
seemed  to  have  perfectly  recovered.  But  in  January,  1897,  severe 
pains  again  occurred.  They  came  on  five  minutes  after  taking 
nourishment,  and  were  increased  by  standing  and  walking.  They 
originated  in  the  pit  of  the  stomach,  and  radiated  behind  the 
sternum  and  into  the  arms  to  the  little  fingers,  thus  resembling 
angina  pectoris.  Each  attack  lasted  from  thirty  to  forty-five 
minutes.  After  fourteen  months  of  suffering,  an  operation  was 
performed  in  March,  i8g8. 

The  stomach  was  surrounded  by  adhesions,  which  were  divided, 
except  the  principal  one,  which  was  very  dense  and  connected 
the  stomach  and  liver.  The  patient  appeared  to  be  relieved,  but 
the  crises  recurred  four  weeks  later  with  the  same  localization 
and  the  same  radiation.  But  they  diff"ered  in  not  being  provoked 
by  food,  appearing  solely  when  the  patient  was  standing  or  walk- 
ing. Thus,  gastric  peristalsis  was  not  painful,  but  the  dragging 
on  the  gastro-hepatic  adhesion  in  the  upright  position,  especially 
after  food,  was.  There  was  a  hard  and  painful  induration  in  the 
epigastric  region.  But  for  the  history,  cancer  might  have  been 
suspected. 

In  June  the  part  of  the  liver  adherent  to  the  stomach  was 
removed  with  the  thermo-cautery,  and  the  wound  was  closed  with 
catgut  sutures.  The  gastric  ulcer  was  resected  in  the  same  way. 
Permanent  relief  followed. 


230  SURGERY  OF  THE  STOMACH 

As  to  the  diagnosis  of  perigastritis,  M.  Merklen  argued 
that  persistence  of  pain  in  spite  of  treatment  was  an  indica- 
tion, and  the  epigastric  induration  a  proof  The  pains  were 
of  two  kinds — those  produced  by  food  and  those  produced 
by  standing.  The  latter  were  explained  by  the  position  of 
the  lesion,  which  was  usually  gastro-hepatic.  Treatment 
consisted  in  dividing  the  adhesions  or  in  resecting  the  ulcer 
and  inflammatory  new  growths. 

In  the  case  of  Mrs.  R.  (seep.  221)  a  second  operation  was 
necessitated  by  the  pain  solely  caused  by  extensive  adhesion 
following  on  the  operation  of  gastroplication  ;  for,  although 
the  stomach  had  been  diminished  in  volume  by  the  previous 
operation  and  the  pylorus  had  remained  patent,  the  ad- 
hesions had  produced  so  much  pain  and  distress  during 
peristalsis  and  on  exertion  that  the  patient  was  entirely 
incapacitated  and  bedridden.  Gastrolysis  was  performed, 
but  as  the  adhesions  were  so  very  extensive,  in  order  that 
the  relief  might  be  permanent  and  complete,  it  was  con- 
sidered advisable  at  the  same  time  to  perform  posterior 
gastro-enterostomy.  The  patient  made  a  good  recovery,  lost 
her  pain,  and  is  now  well. 

The  following  are  illustrative  cases  : 

Ulcer  of  Stomach  ;   Dilatation  ;  Perigastritis.     Gastro- 
lysis. 

Mrs.  A.  H.,  aged  forty-one,  seen  by  Mayo  Robson  September, 
1898.  Fourteen  years  ago  patient  first  noticed  pain  and  tender- 
ness at  the  epigastrium,  which  has  been  worse  since  January,  and 
is  increasing  in  severity.  The  pain  is  paroxysmal,  not  worse  or 
specially  present  after  food,  though  occasionally  food  causes  pain. 
Since  January  she  has  vomited  frequently.  It  is  years  since  any 
blood  was  brought  up.  No  certainty  of  loss  of  weight.  On 
two  or  three  occasions  faeces  have  been  blood-stained  ;  never 
jaundiced.  No  fulness  of  epigastrium.  Visible  peristalsis. 
General  tenderness  of  abdomen  on  palpation,  but  especially  over 
epigastric  region.     Splashing  sounds  obtained. 

September  28,  1898.- — Operation.  Extensive  adhesions  found 
between  gall-bladder,  liver,  and  pylorus.  A  cicatrix  found  in  the 
wall  of  the  stomach.  There  was  no  stricture  of  pylorus,  but  it 
was  found  kinked  owing  to  the  dilated  stomach  dragging  on  the 
adhesions.  Omentum  placed  between  surfaces  to  prevent  further 
adhesions. 


PERIGASTRITIS  231 

Recovery  satisfactory,  and  patient  able  to  take  food  well. 
Later  reports  satisfactory  in  every  respect. 

Pyloric  Ulcer;  Perigastritis;  Adhesions.     Gastrolysis. 

Mrs.  M.  H.,  aged  forty-one,  seen  by  Mayo  Robson  with  Dr. 
McGregor  Young.  For  months  pain  beneath  left  clavicle  and 
indigestion,  with  loss  of  flesh.  Recently  noticed  tumour  in  upper 
abdomen.  Dilated  stomach ;  movable  painless  tumour  in  upper 
abdomen  attached  to  liver. 

Operation.  Perigastritis,  with  adhesions  to  gall-bladder  and 
liver.  Tumour  was  abnormal ;  projection  from  left  lobe  of  liver. 
Adhesions  separated.     Very  good  recovery. 

1900. — Health  regained. 

Perigastritis  ;  Adhesions. 

Dr.  L.,  aged  thirty-three,  seen  by  Mayo  Robson.  Ten  years 
ago  obstruction  of  bowels,  lasting  a  week,  with  vomiting  and 
abdominal  colic.  Similar  attack  a  few  months  later  ;  since  then 
subject  to  bilious  vomiting.  For  two  years  dyspepsia  and  flatu- 
lence with  constipation,  but  no  marked  jaundice.  For  two  years 
pain  in  right  hypochondrium  ;  reheved  by  taking  food.  Never 
vomited  blood.  Loss  of  flesh  and  increasing  debility.  Well- 
marked  tenderness  over  gall-bladder  and  pylorus,  with  dilatation 
of  stomach. 

December  4,  1895. — Operation.  Pylorus  tucked  up  to  liver  and 
kinked.  Adhesions  round  pylorus  separated.  No  gall-stones 
present. 

Good  recovery.    By  March  3,  1896,  had  gained  a  stone  in  weight. 

1900.^ — Well,  and  has  been  engaged  in  full  active  work  as  a 
medical  man  in  a  large  country  practice  ever  since  he  recovered 
from  his  operation. 

Perigastritis  following  Cholelithiasis. 

Mrs.  M.  Z.,  aged  thirty-six,  seen  by  Mayo  Robson.  '  Spasms' 
for  twenty  years.  Cholecystotomy  in  Durban,  Natal,  ten  months 
ago.  Four  gall-stones  removed.  After  healing  of  wound  in  five 
weeks  return  of  pain.  Pain  always  after  food,  and  at  times 
vomiting  ;  never  vomited  blood.  Losing  flesh  rapidly.  Dilata- 
tion of  stomach.     No  tenderness  over  gall-bladder. 

July  6,  1897. — Operation.  Adhesions  between  pylorus  and  gall- 
bladder and  liver  broken  down,  and  omentum  interposed. 

July  6,  1898. — Patient  writes:  'I  now  feel  a  different  person, 
and  enjoy  perfect  health.' 


232  SURGERY  OF  THE  STOMACH 

Perigastritis. 

Miss  M.  S.,  aged  twenty-five,  seen  by  Mayo  Robson  with 
Mr.  F.  H.  Mayo,  Headingley.  Dyspepsia  without  vomiting  for 
sixteen  months  ;  some  pain  after  food.  Latterly  pain  and  dragging 
continuous,  chiefly  in  epigastrium.  Loss  of  flesh.  Dilated 
stomach.  Dieting  and  rest  gave  no  relief.  Small  o\'arian  tumour 
found  on  pelvic  examination  under  ether. 

July  25,  1899. — Operation.  Pylorus  adherent  by  long  band  to 
right  anterior  abdominal  wall.  Adhesions  separated.  Ovariotomy 
for  tumour  performed  at  same  time. 

Well  February,  1900.  Had  lost  previous  troubles  and  gained 
weight. 

Perigastritis  ;  Cholecystitis. 

Dr.  D.  A.,  aged  forty-one,  seen  by  Mayo  Robson  with  Dr. 
Turner,  York.  Ill  since  February,  1898,  when  he  had  influenza, 
followed  by  scarlet  fever  in  March  ;  in  same  year  repeated  similar 
seizures.  At  beginning  of  1899  was  jaundiced  for  six  weeks. 
Latterly  gastric  symptoms  very  prominent.  Pain  and  dragging 
after  food ;  occasionally  vomiting.  Lost  2  stones  3  pounds  in 
weight  in  last  sixteen  months. 

Examination.  Rigid  right  rectus  ;  tenderness  below  ninth 
costal  margin.     No  jaundice  ;  dilatation  of  stomach. 

September  22,  1899. — Operation.  Extensive  adhesions  of  pylorus 
and  pyloric  extremity  of  stomach  to  liver  and  gall-bladder,  which 
was  contracted.  Gastrolysis  and  cholecystotomy.  Adhesions 
separated  and  gall-bladder  drained. 

Well  January,  1900.  Regained  lost  weight,  and  able  to  take 
active  service  in  South  Africa. 

Perigastritis. 

Dr.  M.  D.,  aged  forty-nine,  seen  by  Mayo  Robson  with  Dr. 
McGregor  Young,  Leeds.  Dyspepsia  for  two  years,  with  pro- 
gressive loss  of  weight,  to  the  extent  of  30  pounds  within  the  last 
year.  No  history  of  ulceration.  Questionable  cholecystitis  follow- 
ing influenza. 

Examination.  Rigid  right  rectus,  with  little  tenderness. 
Stomach  dilated.     Patient  thin,  but  not  emaciated. 

December  7,  1899. — Operation.  Many  small  bands,  fixing  the 
pyloric  extremity  of  the  stomach  to  the  gall-bladder,  and  causing 
a  kink  in  the  first  part  of  the  duodenum.     Separation  of  adhesions. 

Good  recovery.     Gained  i  stone  within  two  months. 


CHAPTER  XV 

GASTRIC  FISTULA 

Gastric  fistula,  a  sequel  of  perforation,  may  be  found  occa- 
sionally on  the  surface  of  the  abdomen,  very  rarely  in  the 
loin  (external  gastric  fistula),  but  not  infrequently  between 
the  stomach  and  adjoining  organs  (internal  gastric  fistula). 
It  may  be  pathological  or  traumatic.  The  following  is  an 
etiological  classification : 

Pathological. — Extrinsic :  Cancer  of  the  gall-bladder  or 
bowel ;  gall-stones  ;  empyema  of  the  gall-bladder ;  abscess  of 
the  liver ;  abscess  of  the  pancreas ;  ulcer  of  the  bowel — simple, 
malignant,  or  tuberculous ;  subphrenic  abscess  bursting  into 
the  stomach.  Intrinsic  :  Ulcer  of  the  stomach  or  pylorus ; 
cancer  of  the  stomach  or  p3'lorus ;  foreign  bodies  in  the 
stomach  ulcerating  into  neighbouring  organs ;  subphrenic 
abscess  of  gastric  origin. 

Traumatic— (a)  From  injury,  either  by  a  wound  inflicted 
from  without,  inwards,  or  from  perforation  and  escape  of  a 
foreign  body  previously  swallowed  ;  and  (b)  from  operation — 
gastrostomy  and  gastro-enterostomy. 

Ulcer  of  the  stomach  is  by  far  the  most  frequent  cause  of 
fistula.  It  may  lead  to  perforation  of  the  diaphragm,  and 
thence  to  perforation  of  the  pleura  and  the  lung  ;  to  perfora- 
tion of  the  pericardium  and  the  heart ;  to  general  emphysema, 
owing  to  perforation  and  entrance  of  air  into  the  medias- 
tinum ;  as  well  as  to  the  more  ordinary  cases  of  perforation 
of  the  skin,  leading  to  surface  fistulae,  to  perforation  of  the 
colon  and  gastro-colic  fistula,  to  gastro-duodenal,  gastro- 
gastric,  and  other  fistulse. 

The  symptoms  vary  according  to  the  cause  and  the  site  of 


234  SURGERY  OF  THE  STOMACH 

the  fistula.  If  it  be  between  the  stomach  and  upper  bowel, 
the  symptoms  may  be  slight  or  absent ;  but  if  it  be  between 
the  stomach  and  the  large  bowel,  the  food  will  pass  too  rapidly 
through  the  alimentary  canal,  and  be  parted  wnth  before 
absorption  is  adequate  for  nutrition  ;  and,  on  the  other  hand, 
gases  from  the  colon  entering  the  stomach  will  give  rise  to 
fcetid  eructations,  at  times  to  feculent  vomiting,  and  always 
to  chronic  dyspepsia. 

In  a  case  of  fistula  between  the  gall-bladder  and  stomach, 
dependent  on  gall-stones,  in  a  woman  of  fifty  years  of  age 
who  came  under  the  observation  of  one  of  us  (Mayo  Robson), 
there  w^as  great  loss  of  flesh,  with  frequent  vomiting  of  bile  ; 
for  though  it  is  known  that  healthy  bile  ma}^  pass  through 
the  stomach  without  serious  harm  to  nutrition,  the  patho- 
logical products  from  an  inflamed  gall-bladder,  together  with 
the  infected  bile  associated  wdth  cholelithiasis,  seemed  in 
this  case  to  have  a  very  deleterious  effect.  After  opening  the 
abdomen,  the  fundus  of  the  gall-bladder  was  found  to  be 
firmly  fixed  to  the  stomach  near  the  pylorus,  and  on 
separating  the  adhesions  the  openings  into  the  gall-bladder 
and  stomach  were  found  well  within  reach.  The  stomach 
fistula  was  closed  by  two  layers  of  sutures,  and  then  the 
gall-bladder  was  brought  to  the  surface  and  a  tube  inserted 
for  drainage.  The  patient  made  a  very  satisfactory  recovery, 
and  is  now  quite  w'ell,  having  gained  considerably  in  weight. 

In  another  case  of  abscess  between  the  liver  and  pylorus, 
the  stenosis  caused  by  the  ulcer  produced  such  serious 
symptoms  of  itself  that  it  was  difficult  to  estimate  the  part 
played  by  the  abscess.  In  this  case  also  the  ulcer  was 
excised,  and  the  wound  stitched  up  transversely  to  the 
pyloric  axis,  the  cavity  in  the  liver  being  scraped  out  and 
purified.     The  patient  is  now  in  excellent  health. 

In  a  case  of  fistula  that  we  found  betw^een  the  stomach 
and  pancreas  there  was  dyspepsia,  with  pain  after  food, 
vomiting,  and  great  loss  of  flesh  ;  but  in  this  case  the 
stenosis  of  the  pylorus  and  consequent  dilatation  of  the 
stomach  seemed  to  account  for  the  greater  part  of  the 
trouble. 

Fistulse   on  the  surface  of  the   abdomen,   if  small,   may 


GASTRIC  FISTULA 


235 


cause  little  loss  of  health ;  but  if  extensive,  the  leakage  from 
the  stomach  of  food  and  gastric  juice  leads  to  great  distress 
from  the  soreness  of  the  skin  around  the  fistula,  and  to  loss 
of  flesh  from  the  waste  of  food. 

Kronheimer  {Deut.  ZeitscJir.  f.  CJiir.,  October,  1899)  reported  a 
case,  verified  by  post-mortem  examination,  after  an  unsuccessful 
operation.  The  patient,  aged  forty-five,  was  subject  to  anaemia 
for  nine  years  ;  she  had  never  been  pregnant,  and  the  '  periods ' 
ceased  for  two  months.  Dyspeptic  pains  had  lasted  for  some 
time,  and  fixed  pain  was  at  length  localized  to  a  point  a  little 
below  the  left  hypochondrium.  At  length  violent  vomiting  and 
paroxysmal  aggravation  of  the  fixed  pain  took  place.  The  pain 
was  trifling  when  the  patient  fasted.  A  hard  swelling  developed 
at  the  site  of  the  pain.  Five  months  before  admission  into 
hospital  it  grew  red,  then  soft,  and  burst  a  fortnight  before  ;  dark 
fluid  and  pieces  of  food  began  at  once  to  escape,  and  the  pain 
diminished.  Emaciation  was  advanced ;  the  integuments  were 
intensely  irritated.  Fluids  swallowed  by  the  patient  escaped  in 
jets  through  the  fistula,  and  very  little  nutritive  material  was 
digested,  hence  feeding  through  the  mouth  or  through  the  fistula 
was  impracticable.  Nutrient  enemata  were  given,  but  the  patient 
clearly  could  not  be  kept  alive  for  long  by  such  means.  Hermes 
undertook  an  operation  for  the  excision  of  the  fistula,  but  the 
patient  took  the  anaesthetic  badly,  and  the  heart's  action  was  very 
weak  ;  there  was  also  double  bronchitis.  He  therefore,  having 
made  a  median  incision  above  the  umbilicus,  did  an  enterostomy, 
opening  the  jejunum  directly  after  its  transition  from  the  third 
part  of  the  duodenum.  His  aim  was  to  feed  the  patient  through 
the  jejunal  fistula  till  her  strength  would  allow  of  a  more  complete 
operation.  This  was  practicable,  but  peritonitis  set  in,  and  the 
patient  died  on  the  ninth  day.  A  large  oval  chronic  ulcer  was 
found  in  the  anterior  wall  of  the  stomach,  corresponding  to  the 
fistula. 

Case  under  the  Care  of  Mr.  C.  F.  M.  Althorp 
{Medical  Press,  February  6,  1901). 

The  patient  was  a  woman,  aged  fifty,  who  for  fifteen  months 
before  admission  had  suff'ered  from  abdominal  pain  and  vomiting. 
On  examination  she  was  pale  and  emaciated.  The  abdomen 
was  flat.  Just  below  and  to  the  left  of  the  umbilicus  was  a 
tender  swelling,  about  3  inches  by  2  inches,  in  the  abdominal 
wall,  the  further  connection  of  which  could  not  be  determined. 
In  the  course  of  a  week  an  abscess  formed  at  this  spot.     An 


236  SURGERY  OF  THE  STOMACH 

incision  was  made  on  October  3,  igoo,  under  an  anaesthetic, 
and  a  quantity  of  thin,  foetid  pus  evacuated.  Even  at  this  time 
it  was  not  obvious  what  was  the  cause  of  the  abscess.  The 
wound  in  the  abdominal  wall  did  not  heal,  and  there  was  found, 
after  a  time,  a  second  collection  of  pus  to  the  left  of  the  former 
incision.  On  November  28  this  was  incised,  and  found  to  be 
rather  deeper  than  the  first  abscess,  but  outside  the  peritoneal 
cavity.  In  the  course  of  three  days  the  discharge  from  the 
second  wound  was  found  to  consist  largely  of  gastric  contents. 
In  a  day  or  two  practically  all  the  food  taken  escaped  by  the 
fistula,  and  it  was  thought  this  indicated  some  stenosis  of  the 
pylorus.     The  patient  was  rapidly  losing  ground. 

On  December  7  the  patient  was  placed  under  ether,  and  the 
stomach  washed  out  through  the  fistula,  which  easily  admitted 
the  finger.  The  peritoneal  cavity  was  opened  by  an  incision 
above  and  to  the  right  of  the  fistula,  and  a  broad  pedicle, 
3|-  inches  by  i^  inches,  was  found  passing  from  the  stomach 
to  the  abdominal  wall.  The  portion  of  abdominal  wall  to  which 
the  stomach  was  adherent  was  isolated  by  an  oval  incision,  and 
sterilized  gauze  inserted  to  protect  the  peritoneal  cavity  from 
being  soiled.  This  portion  of  abdominal  wall  was  then  cut 
away  from  the  stomach.  The  fistula  was  found  to  be  the  centre 
of  a  large  ulcer  on  the  greater  curvature,  near  the  pylorus.  There 
was  no  stenosis  of  the  pylorus.  The  edges  of  the  fistula  were 
freshened,  and  the  opening  closed  by  three  rows  of  silk  suture, 
which,  however,  had  to  be  passed  through  greatly  indurated 
tissue.  The  omentum  was  drawn  over  the  spot,  and  fixed  there 
by  several  points  of  suture.  The  abdominal  wound  was  closed 
by  silkworm-gut  sutures  passing  through  the  whole  thickness. 

There  was  great  collapse  after  the  operation.  Rectal  feeding 
and  subcutaneous  injections  of  saline  fluid  were  given  with  good 
effect.  On  the  third  day  small  doses  of  brandy  and  meat  essence 
were  given  by  the  mouth.  The  patient  died  on  the  sixth  day, 
with  symptoms  pointing  to  pneumonia. 

Autopsy. — Pneumonia  of  the  right  lung  was  found.  The  ab- 
dominal wound  was  dry,  and  there  had  been  no  escape  of  gastric 
contents  into  the  peritoneal  cavity.  There  was,  apparently,  no 
attempt  at  union  in  the  stomach  wound,  and  probably,  had  the 
patient  survived,  a  perigastric  abscess  would  have  formed.  The 
pylorus  was  healthy,  and  not  narrowed  by  the  ulcer.  There  was 
no  dilatation  of  the  stomach.  The  ulcer  was  found  to  be  as 
described  at  the  operation.  The  omentum  was  thickened  greatly, 
so  as  to  simulate  malignant  disease.  The  report  of  the  micro- 
scopic examination  showed  that  there  was  no  evidence  of  carci- 
noma. 


GASTRIC  FISTULA  237 

There  are  several  specimens  in  the  Hunterian  Museum. 
No.  2,531  is  a  specimen  of  a  cancerous  ulcer  between  the 
stomach  and  the  colon.  The  disease  probably  commenced 
in  the  colon.  It  occurred  in  a  woman  of  fifty-five  years  of 
age.  Death  was  due  to  exhaustion.  There  was  no  vomiting. 
No.  2,426c  is  a  specimen  of  cancer  of  the  pylorus  involving 
the  transverse  colon.  It  is  from  a  woman  thirty-nine  years 
of  age. 

Diagnosis. 

As  a  rule,  except  in  surface  fistulae,  diagnosis  can  only  be 
made  after  opening  the  abdomen  ;  but  if  unaltered  or  slightly 
altered  food  be  seen  in  the  faeces  after  a  history  pointing  to 
simple  or  malignant  ulceration  of  the  stomach,  a  fistula 
between  the  stomach  and  colon  would  be  suspected, 
especially  if  fcetid  eructations  or  feculent  vomiting  occurred 
from  time  to  time.  The  inability  to  distend  the  stomach 
with  air  pumped  through  an  oesophageal  tube  would  help 
in  the  diagnosis.  The  persistent  nausea  and  vomiting  of 
bile  was  a  marked  symptom  in  the  gall-bladder-stomach 
fistula. 

Treatment. 

In  simple  internal  fistulas,  exploration  by  abdominal  section 
and  closure  of  the  two  openings  may  be  done,  as  in  the  cases 
previously  referred  to.  In  malignant  disease  partial  gastrec- 
tomy and  enterectomy  might  possibly  be  performed  if  the 
disease  could  be  discovered  in  time ;  but  such  a  communica- 
tion would  probably  mean  advanced  disease  and  secondary 
infection,  and  would  therefore,  as  a  rule,  be  beyond  operative 
treatment.  Surface  fistulse  can  be  closed  readily  by  plastic 
procedures,  if  they  do  not  close  spontaneously  under  careful 
dressing  and  rest.  Such  fistulse  may  be  closed  by  carefully 
dissecting,  without  opening,  the  peritoneal  cavity,  and  then 
invaginating  the  margins  of  the  opening  in  the  stomach,  and 
suturing  them  accurately  together  with  two  layers  of  super- 
imposed sutures,  afterwards  closing  the  muscular  and  apo- 
neurotic layers  of  the  abdominal  wall  by  separate  sutures, 
and  lastly  the  skin.     This  operation  is  sometimes  necessary 


238  SURGERY  OF  THE  STOMACH 

in  closing  a  gastrostomy  opening  that  has  been  made  for 
temporary  use. 

The  first  attempts  to  close  a  gastric  fistula  were  by  means 
of  the  cautery,  and  if  the  fistula  be  small  such  means  may  be 
quite  efficient.  In  1859  Middledorpf  introduced  a  simple 
plastic  operation  for  the  purpose. 

In  1877  Billroth  cured  a  patient  by  completely  separating 
the  stomach  from  its  adhesions  to  the  abdominal  wall,  and 
then  closing  the  fistula.  Esmarch  also  resected  a  portion  of 
the  stomach  wall  around  a  fistula,  and  closed  the  opening  by 
sutures.  We  found  in  the  two  cases  mentioned  of  inter- 
visceral  fistulse  that  the  radical  method  of  separating  the 
fistula  from  the  surrounding  adhesions,  and  then  either 
excising  or  inverting  the  raw  edges,  was  attended  with 
satisfactory  results.  In  all  cases  of  surface  fistulse  where 
the  fistula  is  not  very  small,  in  which  case  the  cautery  will 
probably  cure  it,  and  where  it  is  producing  serious  or  trouble- 
some symptoms,  resection  should  be  done,  as  anything  short 
of  this  is  very  likely  to  fail. 


CHAPTER   XVI 

GASTROPTOSIS 

Gastroptosis,  or  a  downward  displacement  of  the  stomach, 
forms  one  of  the  prominent  characteristics  of  a  disease,  often 
dependent  on  a  congenital  deformity,  and  first  described  by 
Glenard  of  Lyons  in  1885,  after  whom  the  disease  has  been 
named. 

In  this  ailment  the  ligaments  or  mesenteries  attaching  the 
various  organs  to  the  parietes  are  lengthened,  thus  allowing 
the  liver  to  descend  below  the  costal  margin,  the  stomach 
below  the  umbilicus,  and  the  intestines,  kidneys  and  other 
viscera  to  be  more  movable  than  occurs  under  normal 
conditions. 

Owing  to  the  displacement,  kinking  of  the  pylorus  or  of 
intestinal  loops  is  apt  to  occur,  leading  in  the  one  case  to 
pyloric,  in  the  other  to  intestinal,  obstruction,  partial  or 
complete. 

Gastroptosis  may  or  may  not  be  accompanied  by  displace- 
ment of  the  other  organs,  but  whether  it  occurs  alone  or  as 
part  of  a  general  abdominal  slackness,  it  can  readily  be 
recognised  by  distending  the  stomach  with  CO.2,  and  by 
palpating  or  percussing  the  outline  of  the  displaced  viscera 
through  the  abdominal  walls. 

The  accompanying  diagram  shows  the  situation  of  the 
stomach  in  the  case,  of  which  brief  notes  are  given  to  illus- 
trate the  symptoms  that  may  be  expected  and  the  surgical 
treatment  that  may  be  adopted. 

The  general  treatment  of  Glenard's  disease  is  by  means  of 
tonics  and  rest,  with  a  well-made  abdominal  belt  in  order  to 
support  and  lift  up  the  depressed  viscera. 


240 


SURGERY  OF  THE  STOMACH 


In  exceptional  cases  this  is  insufficient,  and  where  kinking 
of  the  pylorus  has  led  to  dilatation  of  the  stomach,  with 
dyspepsia,  pain  and  loss  of  flesh,  operative  treatment  may  be 
called  for. 

Duret  of  Lille  was,  we  believe,  the  first  surgeon  to 
perform  gastropexy,  which  he  did  by  fixing  the  pylorus  and 
lesser  curvature  to  the  abdominal  wall.    He  made  an  incision 


Fig.  47. — Gastroptosis,  the  Pancreas  showing  above  the  Lesser 
Curvature. 


in  the  middle  line  above  the  umbilicus,  leaving  the  peri- 
toneum and  transversalis  fascia  undivided  at  the  upper  end 
of  the  incision.  Sutures  were  then  passed  fixing  the  lesser 
curvature  of  the  stomach  to  this  undivided  fascia,  thus 
correcting  the  excessive  mobility  of  the  organ. 

Should  there  be  pyloric  stenosis  and  dilatation,  such  an 
operation  would  be  insufficient,  and  pyloroplasty  or  gastro- 
enterostomy would  be  necessary. 


GASTROPTOSIS  241 

Stengel  and  Beyea  {American  Journal  of  Medical  Science, 
June,  1899)  record  a  case  of  Glenard's  disease  treated  by 
operative  procedure. 

The  patient  was  a  young  unmarried  woman,  without  history 
of  injury,  abdominal  distension  or  emaciation.  At  the  time  of 
observation  she  had  already  undergone  nephrorrhaphy,  which  was 
followed  by  some  general  improvement.  It  was  found,  however, 
that  the  gastric  symptoms  remained  much  as  before.  Examina- 
tion of  the  abdomen  showed  some  sinking  in  at  the  epigastrium 
and  a  protuberance  at  the  umbilicus,  which  was  found  to  be  the 
stomach,  the  lesser  curvature  extending  from  i^  inches  above  the 
umbilicus  to  a  point  two-thirds  the  distance  from  the  umbilicus  to 
the  pubes,  behind  which  was  the  greater  curvature.  The  right 
border  extended  to  the  right  of  the  umbilicus  i^  inches,  the 
pylorus  being  slightly  to  the  right  of  the  middle  line  and  a  little 
above  the  umbilicus.  No  evidence  of  growth  could  be  found. 
The  digestive  processes  seemed  slow.  There  was  no  lactic  acid 
reaction.  It  was  decided  to  operate,  and  the  following  was  the 
procedure  adopted  :  An  incision  was  made  through  the  linea  alba 
midway  between  the  xiphoid  and  umbilicus,  exposing  a  small 
portion  of  the  upper  curvature  and  cardiac  end  of  the  stomach, 
the  gastro-hepatic  omentum,  the  gastro-phrenic  ligaments,  and 
the  lower  portion  of  the  liver.  At  the  beginning  of  the  operation 
the  patient's  shoulders  were  slightly  raised,  but  at  this  stage  the 
position  was  reversed  to  allow  the  stomach  to  fall  back  into  posi- 
tion. The  gastro-hepatic  omentum  and  gastro-phrenic  were 
exposed,  separated  from  underlymg  structures,  and  interrupted 
sutures  were  introduced  to  shorten  the  gastro-hepatic  omentum  in 
the  following  manner :  The  first  suture  caught  the  gastro-phrenic 
ligament  above  at  a  point  as  near  as  possible  to  the  diaphragm  (a 
distance  of  about  2  inches  from  the  diaphragm)  and  below,  just 
above  the  gastric  vessels.  After  this  suture  had  been  placed,  the 
gauze  sponges  which  had  displaced  the  stomach  were  removed 
and  the  suture  temporarily  tightened,  so  as  to  determine  the 
height  to  which  the  stomach  could  be  brought  by  this  manner  of 
suturing,  and  the  degree  of  support  which  would  be  furnished  to 
the  stomach.  This  having  been  determined  to  be  satisfactory, 
the  stomach  was  again  displaced  out  of  the  wound  and  the  suturing 
continued.  The  second  suture  was  introduced  through  the  gastro- 
hepatic  omentum  opposite,  and  about  \  inch  from  the  first  one, 
followed  by  a  row  of  eight  or  ten  others  introduced  in  the  same 
way,  to  include  the  left  three-fourths  of  the  gastro  -  hepatic 
omentum.  In  order  to  be  sure  of  gaining  a  wide  surface  of 
adhesion,   particularly  in  relation   with    the   gastro-phrenic  liga- 

16 


242  SURGERY  OF  THE  STOMACH 

ment,  three  or  four  more  sutures  were  introduced,  which  included 
the  peritoneum  above  and  below  those  already  placed.  The 
gauze  sponges  were  again  removed,  and  the  first  and  then  the 
second  row  of  sutures  were  tied,  forming  a  tuck  in  the  gastro- 
hepatic  omentum  and  gastro-phrenic  ligament.  After  this  had 
been  accomplished,  the  stomach  was  seen  to  occupy  what  was 
thought  to  be  a  normal  position.  All  gauze  sponges  were  then 
removed  from  the  abdominal  cavity,  and  the  table  lowered  until 
the  patient  was  in  a  horizontal  position.  The  patient  made  an 
uninterrupted  recovery,  leaving  the  hospital  in  two  months  and 
ten  days  from  the  time  of  the  operation.  Some  months  later 
examination  showed  that  the  lesser  curvature  was  still  well  sup- 
ported, and  that  the  greater  did  not  extend  more  than  ih  inches 
below  the  umbilicus.  Eleven  months  after  the  operation  the 
woman  was  found  better  in  every  way  ;  she  had  gained  con- 
siderably in  weight,  was  able  to  eat  freely  without  discomfort, 
appetite  and  energy  being  distinctly  good. 

The  authors  appear  strongly  inclined  to  recommend 
this  operation  in  cases  of  gastroptosis  in  which  there  are 
abdominal  pain,  vomiting,  and  all  the  ill-effects  due  to  dilated 
stomach  and  disturbed  digestion. 


CHAPTER  XVII 
TUBERCLE-SYPHILIS— PHLEGMONOUS   GASTRITIS 

Tuberculosis  of  the  Stomach. 

The  insusceptibility  of  the  mucous  membrane  of  the  stomach 
to  become  affected  with  tubercle  presents  a  great  contrast  to 
that  of  the  intestinal  lining,  for  primary  tubercular  ulcera- 
tion of  the  stomach  is  extremely  rare,  and  even  secondary 
tuberculous  ulceration  is  so  rare  that  Dr.  M.  Simmonds 
{Miinch.  Med.  Woch.,  March  6,  i8gg,  p.  317)  only  found  eight 
specimens  among  2,000  tuberculous  subjects. 

Gastric  disorders,  however  brought  about,  must  be  con- 
sidered among  the  predisposing  causes  of  tubercular  disease, 
and  especially  of  tubercular  disease  of  the  mucous  membrane. 
The  ulcers,  which  may  be  solitary  or  multiple,  are  usually 
small,  with  undermined  and  ragged  edges  owing  to  infiltra- 
tion and  breaking  down  of  the  submucous  tissue,  like 
tubercular  abscess  in  the  small  intestine. 

The  following  are  brief  notes  of  a  case  on  which  an 
operation  was  performed  on  account  of  pyloric  stenosis  and 
vomiting  due  to  tubercle  affecting  the  pylorus  : 

On  August  22,  1895,  one  of  us  (Mayo  Robson)  was  asked  by 
Dr.  J.  Lewis  Owen,  of  Llangefni,  to  see  Miss  T.,  aged  nineteen, 
who  gave  a  history  of  pain  after  food  with  occasional  coffee- 
ground  vomiting  for  the  preceding  four  years,  though  the  loss  of 
flesh  had  only  been  very  pronounced  during  six  months,  during 
which  time  she  had  been  able  to  take  very  little  food  on  account 
of  sickness  and  pain.  Four  months  before  we  saw  her,  dilatation 
of  the  stomach  due  to  pyloric  stricture  had  been  diagnosed,  and 
lavage  of  the  stomach  had  been  followed  out  for  a  month  without 
benefit.  She  was  extremely  pale,  and  so  thin  that  the  skin  was 
tightly  stretched  over  her  bones.      She  only  weighed  4  stones 

16 — 2 


244  SURGERY  OF  THE  STOMACH 

lo  pounds.  Tubercular  glands  Avere  felt  in  the  neck,  and  there 
was  a  little  swelling  of  the  abdomen  due  to  free  fluid  in  the 
peritoneum.  The  stomach  was  markedly  dilated,  and  the  pylorus 
could  be  felt  thickened  and  movable.  As  she  was  clearly  going 
to  die  unless  relieved,  operation  was  performed  on  August  27, 
1895.  On  opening  the  abdomen  some  fluid  escaped  from  the 
peritoneum.  There  Avere  tubercular  nodules  on  the  stomach  and 
omentum,  and  the  mesenteric  glands  were  found  to  be  full  of 
caseous  material  and  pus.  The  pylorus  was  nodular  and  thickened, 
and  was  itself  the  seat  of  tubercle  ;  the  stomach  w^as  enormously 
dilated. 

Pyloroplasty  was  performed,  but  before  closing  the  wound  in 
the  pylorus  the  finger  was  passed  into  the  duodenum,  as  a 
constriction  could  be  seen  an  inch  beyond  the  pylorus.  Here  was 
found  a  stricture  that  would  admit  the  little  finger.  Through  this 
a  Weiss'  dilator  was  passed,  and  it  was  dilated  freely  until  the 
thumb  would  readily  pass.  After  the  pyloroplasty  had  been 
completed  the  abdomen  was  closed.  The  after-progress  appeared 
to  be  satisfactory,  and  the  wound  healed  by  first  intention,  the 
stitches  being  removed  at  the  sixth  day  ;  but  no  real  gain  of 
strength  was  made,  and  the  patient  died  exhausted  in  the  second 
week. 

It  is  the  only  case  of  the  kind  that  has  come  under  our 
care,  but  Patella  (British  Medical  Journal,  SuppL,  399,  1900, 
p.  82),  at  the  Congress  on  Tuberculosis  recently  held  at 
Naples,  said  he  had  seen  three  cases  of  stenosis  of  the 
pylorus  caused  by  fibrous  peripyloritis  developing  in  indi- 
viduals who,  at  least  three  years  previously,  had  presented 
SA-mptoms  of  tuberculous  lesions  of  the  lung,  which  had 
passed  into  the  phase  of  obsolescence.  In  two  of  the  cases 
gastro-enterostomy  had  been  performed  by  Golzi  and  De 
Pauli,  with  the  result  that  the  patients,  who  were  in  a  state 
of  extreme  marasmus,  regained  weight  and  strength.  In 
these  cases,  in  addition  to  thickening  of  the  p}-lorus,  there 
were  found  nodules  of  fibrous  appearance ;  examination 
showed  that  these  were  not  of  tuberculous  nature.  The 
author  affirms  that  the  conditions  found  gave  no  ground  for 
the  belief  that  the  peripyloritis  Avas  tuberculous  ;  he  thinks 
that  they  are  examples  of  slow  sclerosis  dependent  on  tuber- 
culous intoxication,  the  effect  of  which  may,  according  to 
Potain   and   his  school,   become  manifest   in    various  parts, 


TUBERCULOSIS  OF  THE  STOMACH  245 

especially  where  (as  at  the  pylorus)  there  is  considerable 
movement.  Whatever  be  the  interpretation  of  the  condi- 
tion, he  urges  that  in  such  cases  surgical  intervention  should 
not  be  delayed. 

Tuberculous  ulcers  may  attain  a  great  size  (though  this  is 
exceptional),  as  in  one  of  Dr.  Simmond's  cases  (Medical 
Review,  igoo,  p.  463),  where  the  ulcer  measured  8  inches  by 
4  inches,  its  true  nature  only  being  recognised  on  micro- 
scopical investigation.  It  is  curious  that  this  ulcer  produced 
no  symptoms  during  life.  The  occurrence  of  tuberculous 
ulcers  has  been  described  by  Eppinger,  Prag.  Med.  Woch., 
1881,  No.  51,  52  ;  by  Litten,  Virchow's  Arch.,  B.  67,  p.  615  ; 
by  Musser,  Philad.  Hosp.  Rep.,  1890,  vol.  i.,  p.  170 ;  and 
Blumer,  British  Medical  Journal,  SuppL,  i8g8,  par.  504. 

Petruschky's  views  as  to  the  tuberculous  character  of 
chronic  gastric  ulcers  is  not  supported  either  by  the  clinical 
experience  of  these  cases  treated  surgically  or  by  post- 
mortem evidence.  He  claims  to  have  diagnosed  tubercular 
ulcers  of  the  stomach  by  the  reaction  obtained  with  tuberculin, 
which  in  one  case  proved  curative  and  in  the  other  palliative. 
This  claim  will  have  to  be  supported  by  much  clearer  evidence 
than  has  yet  been  advanced  before  it  can  be  received  as 
distinctly  proven. 

As  complications  of  tuberculous  gastric  ulcer,  hsematemesis 
and  perforation  have  been  described,  but  from  the  chronicity 
of  the  ulceration,  as  well  as  from  the  infrequent  occurrence  of 
tubercular  ulcers,  such  accidents  are  extremely  rare.  Miliary 
tubercle  may  affect  any  of  the  coats  of  the  stomach,  and  in 
this  form  tubercular  disease  is  by  no  means  uncommon.  It 
was  well  marked  in  the  case  we  have  described,  and  is 
commonly  seen  in  tubercular  peritonitis,  as  well  as  in  other 
general  tuberculous  diseases. 

Syphilis  of  the  Stomach. 

Syphilis  of  the  stomach  may  occur  under  the  form  of  ulcer, 
stricture,  or  tumour.  Some  writers  regard  syphilis  as  an 
important  factor  in  relation  to  gastric  ulcer,  one  author 
giving  the  frequency  of  gastric  ulcer  as  high  as  20  per  cent, 
in  syphilitic  subjects,  and  others  as  from  10  to  15  per  cent. 


246  SURGERY  OF  THE  STOMACH 

Dr.  Fenwick  ('Ulcer  of  Stomach,'  p.  93),  while  stating 
that  10  per  cent,  of  cases  of  chronic  ulcer  of  the  stomach 
had  suftered  from  syphilis  at  one  time  or  another,  remarks 
that  it  is  extremel}'  probable  that  in  at  least  one-half  of  such 
cases  where  the  two  diseases  co-exist  in  the  same  patient 
there  is  no  direct  relationship  between  them.  Lesions  due 
to  syphilis,  having  no  clinically  distinctive  features,  can  only 
be  recognised  by  the  history,  the  presence  of  syphilis  in  other 
regions,  and  the  result  of  the  treatment. 

In    the    Philadelphia   Medical  Journal,   February    3,    1900, 


Fig.  48. — Cardiac  Orifice  of  Stomach  obstructed  by  a  Gumma,  which 
also  involves  the  adjoining  portion  of  the  liver. 

From  a  gentleman,  forty-six  years  of  age,  who  died  of  starvation. 

p.  262,  Max  Einhorn  gives  examples  of  ulcer,  gumma,  and 
pyloric  stricture,  all  of  which  yielded  to  treatment  by 
mercury  or  iodide  of  potassium.  The  cases  are  of  sufficient 
interest  and  importance  to  be  worth  quoting. 

Ulcer. 

Case  i. — A  woman,  aged  thirty,  had  for  three  months  suffered 
from  violent  pains  immediately  after  meals,  and  occasional  vomit- 
ing. The  ordinary  treatment  of  gastric  ulcer  had  failed.  She 
had  acquired  syphilis  three  years  previously,  and  had  recovered 
under  mercurial  inunction. 

There  were  violent  pains  after  taking  even  fluids,  such  as  milk, 
bouillon,  etc.     The  pains  lasted  for  one  or  two  hours,  and  were 


SYPHILIS  OF  THE  STOMACH  247 

sometimes  attended  by  vomiting.  There  were  pains  in  the  lower 
limbs,  which  were  more  marked  at  night,  and  the  tibiae  were 
tender.  Syphilitic  ulcer  of  the  stomach  was  diagnosed.  jNIer- 
curial  inunctions  were  employed,  and  iodide  of  potassium  was 
given.  After  fourteen  days  the  pains  disappeared,  and  solid  food 
could  be  taken.     Recovery  was  complete  at  the  end  of  six  weeks. 

Case  2. — A  woman,  aged  thirty-three,  had  acquired  syphilis  at 
twenty- six.  Pains  after  eating  had  existed  for  two  years.  Pro- 
fuse haematemesis  had  occurred.  Under  treatment  for  gastric 
ulcer  she  recovered,  except  that  she  did  not  regain  her  former 
health,  and  complained  almost  constantly  of  dyspeptic  symptoms. 
A  short  time  before  she  came  under  observation,  a  second  severe 
attack  of  hsmatemesis,  accompanied  by  melgena,  occurred. 

The  patient  was  extremely  anaemic  and  confined  to  bed.  There 
were  constant  pains  in  the  stomach,  which  radiated  towards  the 
back,  and  were  increased  even  by  liquid  foods.  During  six  weeks 
fluid  diet  and  bismuth  were  prescribed.  The  vomiting  ceased, 
but  the  pain  persisted.  Iodide  of  potassium  was  then  given. 
In  a  few  days  the  pains  diminished  ;  after  three  weeks  they  had 
disappeared,  and  ordinary  diet  could  be  taken.  Permanent  re- 
covery ensued. 

Gastric  Tumour. 

Case  i. — A.  woman,  aged  thirty-five,  had  contracted  syphilis  at 
thirty-three.  For  six  months  she  had  had  pains  after  meals,  and 
occasional  vomiting.  A  nodular  tumour  about  the  size  of  a 
goose-egg  was  felt  under  the  left  costal  margin.  It  was  beneath 
the  abdominal  wall,  and  moved  on  deep  inspiration.  Below  the 
tumour  a  splashing  noise  could  be  elicited.  The  gastric  region 
was  tender.  In  the  back  a  tumour  of  bony  hardness  extended 
from  the  third  to  the  sixth  dorsal  vertebrae.  The  presence  of  this 
tumour  and  the  history  led  to  the  diagnosis  of  gumma  of  the 
stomach,  although  the  nodular  gastric  tumour  was  suggestive  of 
cancer.  Under  inunction  and  iodide  of  potassium  improvement 
took  place,  and  in  a  few  weeks  both  tumours  disappeared. 

Case  2. — A  man,  aged  fifty,  had  acquired  a  chancre  at  thirty- 
two,  and  for  eighteen  years  had  had  severe  gastric  troubles, 
anorexia,  and  sleeplessness.  Three  years  previously  abdominal 
pains  began,  and  he  lost  15  pounds  in  weight.  In  the  epigastrium 
a  slight  oval  resistance  was  felt  over  an  area  the  size  of  a  hen's 
egg.  Under  iodide  of  potassium  he  regained  weight,  and  the 
tumour  disappeared. 


248  SURGERY  OF  THE  STOMACH 

Pyloric  Stricture. 

A  man,  aged  thirty-seven,  had  acquired  syphilis  at  thirty,  for 
which  he  was  treated  for  several  months.  After  four  years 
dyspeptic  symptoms  began.  He  was  attacked  with  pains  some 
time  after  eating,  and  occasionally  with  vomiting.  During  the 
last  year  he  had  lost  30  pounds  in  weight,  the  symptoms  became 
much  worse,  and  he  lived  chiefly  on  liquid  food.  He  had  to 
wash  out  his  stomach  two  or  three  times  daily,  otherwise  the 
pains  became  unbearable. 

He  was  weak  and  emaciated.  The  stomach  was  dilated, 
extending  to  the  symphysis  pubis.  Gastric  peristalsis  was 
visible.  An  oval  tumour  larger  than  a  pigeon's  eg^g  Avas  felt 
in  the  mammary  line  under  the  right  costal  border.  Under 
fluid  diet,  resorcin,  and  bismuth,  the  pain  and  vomiting,  after 
fourteen  days,  diminished,  but  the  tumour  remained  unchanged. 
Iodide  of  potassium,  10  grains,  three  times  a  day,  was  then  given. 
After  another  fourteen  days  the  tumour  had  diminished,  the  pains 
had  almost  completely  disappeared,  and  the  vomiting  no  longer 
•occurred.  A  month  later  the  tumour  could  not  be  felt,  and  the 
patient's  condition  was  improved.  He  was  soon  able  to  take 
solid  food,  and  in  four  months  he  gained  20  pounds  in  weight. 

Dieulafoy  {Bull,  de  V Academic  dc  Med.,  p.  578,  1898) 
published  a  case  in  which  the  symptoms  of  ulcer  of  the 
stomach  resisted  all  ordinar}^  methods  of  treatment  for 
eighteen  months,  and  then  yielded  rapidly  to  biniodide  of 
mercury.  G.  Andral,  in  1834,  described  two  cases  {Medical 
Review,  March,  1900,  p.  154).  In  one,  a  woman,  aged  twenty- 
nine,  lost  appetite,  was  tormented  with  pains  after  meals, 
and  frequently  vomited.  During  three  months  all  kinds  of 
treatment  failed.  Pains  in  the  neck  on  swallowing  were 
then  complained  of,  and  a  number  of  ulcers  of  syphilitic 
appearance  were  discovered  in  the  pharynx.  The  question 
then  arose.  Were  there  similar  ulcers  in  the  stomach  ? 
Under  mercury  recovery  took  place  in  a  few  weeks. 

Virchow,  Klebs,  Birch- Hirschfeld,  Dalgleish,  and  others, 
have  also  described  isolated  cases. 

Dr.  Simon  Flexner  {American  Journal  of  Medical  Sciences, 
October,  1898)  contributes  a  valuable  article  on  this  subject. 
The  literature  is  very  meagre ;  he  could  find  only  fourteen 
reliable    cases,    of    which   thirteen   were    German    and   one 


SYPHILIS  OF  THE  STOMACH  249 

French.  According  to  him,  there  is  no  instance  recorded 
in  the  English  language.  This  is  scarcely  correct.  In  the 
British  Medical  Journal,  i8gi,  ii.,  p.  6g6,  Dr.  J.  Keser  has 
recorded  the  case  of  a  young  woman  treated  at  the  French 
Hospital,  the  subject  of  secondary  syphilis,  who  had  all  the 
symptoms  of  gastric  ulcer.  She  was  treated  with  bismuth 
and  nitrate  of  silver,  and  fed  by  the  rectum ;  but  only 
temporary  improvement  took  place,  and  the  haematemesis 
continued.  Various  drugs  were  tried  without  success.  The 
constitutional  disease  was  then  discovered,  and  the  patient 
at  once  improved  under  specific  treatment.  The  subject  has 
recently  attracted  the  attention  of  clinicians.  M.  Dieulafoy 
discussed  the  subject  at  the  Academic  de  Medecine  on 
May  17.  He  concluded  that  gastric  syphilis  is  not  so 
uncommon  as  is  supposed,  and  that,  as  the  symptoms  differ 
in  no  way  from  those  of  simple  ulcer,  a  history  should  be 
sought  in  everj^  case.  In  La  France  Medicale,  July  i,  i8g8, 
Dr.  Dubec  has  published  the  case  of  a  man,  the  subject  of 
tertiary  syphilis,  in  whose  stomach  an  indurated  plaque 
could  be  felt,  which  diminished  rapidly  under  mercury  and 
iodide  of  potassium.  The  Transactions  of  the  Pathological 
Society  of  London  do  not  contain  a  single  reference  to  the 
subject.  Of  the  fourteen  cases,  five  were  of  the  inherited, 
and  nine  of  the  acquired,  form.  The  lesions  found  were 
gummata,  ulcers,  and  cicatrices,  and  were  usually  accom- 
panied by  syphilitic  disease  of  other  viscera,  and  sometimes 
by  intestinal  ulcers.  All  the  acquired  cases  appear  to  have 
been  in  the  tertiary  stage,  but  some  of  the  congenital 
occurred  in  new-born  infants.  Chiari  paid  special  atten- 
tion to  gastric  syphilis.  In  243  necropsies  where  syphilitic 
lesions  were  found  there  were  two  cases  of  gastric  syphilis. 

Dr.  Flexner  records  the  case  of  a  man,  aged  fifty-two, 
whose  illness  extended  over  three  years.  He  had  severe 
vomiting,  following  on  a  drinking  bout.  The  spleen  was 
enlarged,  ascites  appeared,  and  then  anasarca  of  the  legs 
and  scrotum.  He  was  repeatedly  tapped ;  3I  gallons  of 
fluid  were  withdrawn  on  the  first  occasion.  The  liver  was 
hard,  but  there  was  no  increase  of  the  area  of  dulness. 
Before  death  he  suffered  from  intense  abdominal  pain  and 


250  SURGERY  OF  THE  STOMACH 

tympanites.  The  necropsy  showed  old  adhesions  between 
liver,  stomach,  spleen,  and  pancreas  ;  the  liver  gummatous 
and  its  capsule  thickened  ;  perforating  ulcer  of  the  stomach ; 
the  spleen  enlarged  and  its  capsule  cartilaginous. 

It  will  be  seen  that  from  a  surgical  point  of  view  the 
subject  is  of  great  importance,  since  it  would  be  easy  to 
mistake  a  gummatous  tumour  of  the  stomach  or  pylorus 
for  cancer,  and  perform  gastrectomy  when  simple  medical 
treatment  would  do  all  that  is  required.  The  lesson  to  be 
learnt  is  that  inquiries  with  regard  to  syphilis  should  always 
be  made  in  ulcer  or  tumour  of  the  stomach,  and  antisyphilitic 
treatment  should  be  given  a  trial  before  resorting  to  more 
radical  surgical  means. 

But  while  the  question  of  syphilis  is  to  be  borne  in  mind, 
it  must  not  be  forgotten  that  gummata  of  the  stomach  are 
extremely  rare  even  in  cases  of  congenital  syphilis,  and  that 
too  much  time  must  not  be  lost  in  medical  treatment  in  a 
doubtful  case,  lest  the  disease  advance  too  far  for  surgical 
treatment  to  be  of  service. 

Phlegmonous   Gastritis. 

Phlegmonous  gastritis  in  seen  in  two  forms  :  the  diffuse 
and  the  circumscribed. 

The  diffuse  form  is  an  exceedingly  acute  and  an  invari- 
ably fatal  disease.  There  is  no  record  of  any  case  having 
recovered,  though  two  museum  specimens  of  Dittrich's  are 
considered  as  showing  that  recovery  is  possible.  The 
symptoms  are  :  sudden  onset  of  epigastric  pain,  tenderness 
and  rigidity  over  the  stomach,  vomiting  of  bile-stained  fluid 
chiefly,  high  temperature,  extreme  weakness  and  restlessness, 
acute  peritonitis,  delirium  and  coma.  The  mean  duration 
of  life  is  six  and  a  half  days. 

At  a  meeting  of  the  American  Medical  Congress  in  May, 
1900  {British  Medical  Journal,  SuppL,  1900),  Kinnicutt  of 
New  York  showed  a  specimen  from  a  case  of  acute  phleg- 
monous gastritis. 

The  patient  was  a  man,  aged  forty-one  years.  There  was  no 
history  of  syphilis,  but  the  patient  was  an  alcoholic.  The  disease 
followed  a  drinking  spell,  and  was  ushered  in  by  vomiting,  first 


PHLEGMONOUS  GASTRITIS  251 

of  food,  and  later  of  a  brownish  fluid.  There  was  abdominal  pain, 
constipation,  dry  tongue,  shallow  respiration,  48  per  minute, 
regular  pulse,  108  per  minute,  restlessness,  and  an  anxious 
expression.  The  temperature  was  101°  in  the  rectum.  The 
physical  examination  was  negative,  except  for  a  slight  hyper- 
trophy of  the  left  ventricle.  The  abdominal  walls  were  rigid  and 
deep  ;  palpation  was  sensitive  in  the  epigastric  and  left  hypo- 
chondriac regions.  There  was  crepitation  beneath  the  left  costal 
cartilages.  The  urine  contained  casts.  The  patient  grew  pro- 
gressively worse,  and  surgical  intervention  was  deemed  inadvis- 
able. At  the  necropsy  the  organs  were  normal,  except  for  the 
hypertrophy  of  the  left  ventricle  of  the  heart,  before  alluded  to. 
The  peritoneum  presented  a  slight  sero-fibrinous  exudate.  The 
stomach  wall  was  thick,  especially  at  the  pyloric  end.  The 
thickening  was  due  to  a  purulent  infiltration  of  the  submucous 
coat,  with  a  yellowish  exudate.  There  was  a  linear  cicatrix  on 
the  posterior  wall  of  the  stomach,  near  the  pylorus,  on  which 
was  a  necrotic  area.  The  endothelium  was  desquamated  on  the 
serous  coat.  The  muscle  was  invaded  by  mononuclear  leucocytes. 
The  submucosa  was  swelled  to  four  or  five  times  its  normal 
thickness,  and  contained  leucocytes  and  micro-organisms.  The 
lymphatics  contained  bacteria.  The  necrotic  area  in  the  scar 
had  nearly  exposed  the  submucosa,  and  was  possibly  the  point  of 
infection.  The  streptococcus  was  found  throughout  the  stomach. 
The  bacilli  in  the  lymphatics  were  possibly  of  post-mortem 
origin. 

In  the  discussion,  W.  H.  Welch  stated  that  he  had  seen 
a  similar  case,  in  which  there  was  a  fibrino-purulent  peri- 
tonitis. The  patient  was  an  alcoholic.  The  pus  was  found 
principally  in  the  submucous  coat  of  the  stomach.  E.  G. 
Janeway  had  seen  three  primary  cases  and  two  secondary 
cases.  One  of  the  patients  was  not  a  drinking  man,  and  the 
two  secondary  cases  followed  sepsis,  and  were  local  in  their 
areas  of  involvement. 

The  circumscribed  form  leads  generally  to  abscess  in  the 
wall  of  the  stomach.  The  symptoms  are  :  intense  epigastric 
pain  and  tenderness  appearing  suddenly,  but  gradually 
lessening  in  their  acuteness.  There  is  an  irregular  elevation 
of  temperature,  and  vomiting  is  a  prominent  symptom.  The 
illness  lingers,  and  the  patient  becomes  sallow,  pinched,  and 
wasted.  A  tumour  of  rounded  form  may  be  observed,  and 
the  vomiting  of  pus.     In  one  example  a  pint  of  pure  pus  was 


252  SURGERY  OF  THE  STOMACH 

vomited  in  the  presence  of  the  physician.  In  others  the 
vomiting  of  pus  gave  reHef,  and  the  illness  passed  off. 

Stiedel  {Deut.  Zeit.fiir  Chir.,  56)  has  related  the  occurrence 
of  phlegmonous  gastritis  spreading  from  a  pyloric  ulcer,  and 
leading  to  purulent  peritonitis,  after  gastro-enterostomy, 
when  the  suture  line  was  found  intact  and  soundly  healed. 

Treatment. — Surgical  intervention  in  cases  of  circumscribed 
gastritis  leading  to  the  formation  of  abscess  is  clearly  indi- 
cated. The  diagnosis,  however,  is  so  uncertain  that  few 
opportunities  of  treating  such  cases  will  be  found. 


CHAPTER  XVni 
OPERATIONS  UPON  THE  STOMACH 

Gastrostomy. 

The  purpose  of  this  operation  is  to  form  an  artificial 
opening  into  the  stomach,  to  permit  of  food  being  adminis- 
tered when  the  cesophagus  is  rendered  impassable  by 
stricture. 

The  operation  was  first  suggested  in  1837  by  Egeberg,  a 
Norwegian  military  surgeon.     He  spoke  of  the  possibility  of 


Fig.  49.— Mayo  Robson's  Bone  Bobbins. 

making  '  an  opening  into  the  cavity  of  the  stomach,  either 
for  injecting  a  sufficient  quantity  of  food  or  for  attacking  an 
oesophageal  stricture  from  below.' 

The  cases  of  Voigtel  and  Beaumont  had  shown  that  a 
gastric  fistula  was  compatible  with  life,  and  experiments 
performed  upon  dogs  by  Blondlot  ('  Traite  Analytique  de  la 
Digestion,'  1843)  suggested  the  possibility  of  successful 
operations  upon  man.  The  first  operation  was  performed 
on  November  13,  1849,  by  Sedillot,  the  patient  dying  in  a 


254 


SURGERY  OF  THE  STOMACH 


few  hours.  In  1875  Sydney  Jones,  who  had  twice  operated 
without  success,  performed  a  gastrostomy  upon  a  patient 
who  survived  twent\-  days;  and  in  1876  Verneuil  operated 
upon  a  patient  who  Hved  sixteen  months.  In  Sedillot's  first 
operation  the  stomach  was  opened  immediately ;  in  his 
second  an  interval  of  five  days  was  allowed  to  elapse  between 
the  fixing  of  the  stomach  to  the  abdominal  wall  and  the 
opening  of  the  stomach.  This,  the  first  operation  a  denx 
temps,  was  performed  on  January  21,  1853. 

The  variety  of  methods  suggested  for  opening  the  stomach 
is    almost    bewildering.     All    the  methods  which    now    find 


Fig.  50.— }iIavo  Robsox's  Bone  Bobbins  (Larger  SizesV 

favour  have  as  their  chief  principle  the  formation  of  a 
valvular  orifice,  so  that  fluid  is  readily  introduced  into  the 
stomach,  but  is  unable  to  escape  from  it.  The  evils  which 
result  from  the  dribbling  of  the  gastric  juice  on  to  the 
surface  of  the  abdomen  are  intolerable.  The  skin  is  digested, 
is  of  a  vivid  red  colour,  and  looks  angry  and  florid.  The 
pain  is  described  as  unendurable,  and  the  patient  welcomes 
death  as  a  release  from  suffering.  With  any  one  of  the 
modern  operations  a  leakage  should  never  occur. 

The  operations  which  we  consider  the  most  satisfactory 

are  : 

1.  Frank's  operation. 

2.  Senn's  operation. 

3.  Witzel's  operation. 

4.  Kader's  operation. 


OPERATIONS  UPON  THE  STOMACH 


255 


I.  Frank's  Method  {^Wien,  Klin.  Woch.,  1893 — variously 
described  as  '  Ssbanajew-Frank's,'  '  Albert-Frank's,'  or 
'i\.lbert-Frank-Kocher's '). — We  have  employed  this  method 
in  a  large  number  of  cases,  and  are  eminently  satisfied  with 
it.     When    the    patient   is   much    reduced    in   strength,   the 


Fig.  51. — Gastrostomy.     (Senn's  ^Method. 


anaesthesia  of  cocaine  is  quite  sufficient,  a  general  anaesthetic 
not  being  necessary.  The  following  modification  of  the 
original  procedure,  first  suggested  and  adopted  by  Mayo 
Robson,  is  employed  : 

A  vertical  incision   of  about  ih  inches  is  made  over  the 


256 


SURGERY  OF  THE  STOMACH 


outer  third  of  the  left  rectus  abdominis,  commencing  f  inch 
below  the  costal  margin  ;  the  fibres  of  the  rectus  are 
separated,  but  not  divided,  to  the  extent  of  the  incision,  and 
the  posterior  part  of  the  rectus  sheath  and  peritoneum  are 
di^•ided  together,  the  opening  being  an  inch  in  length.  A 
portion  of  the  cardiac  end  of  the  stomach  is  then  brought  up 
through  the  wound  and  held  forward  by  an  assistant  until 


Fig.  52. — Gastrostomy.     (Frank's  Method  Modified.) 


four  sutures  are  inserted  into  the  base  of  the  cone  by  means 
of  a  curved  intestinal  needle,  so  as  to  fix  the  visceral  peri- 
toneum of  the  stomach  to  the  edges  of  the  parietal  peritoneum. 
A  transverse  incision  of  |  inch  is  then  made  through  the 
skin  I  inch  above  the  upper  end  of  the  first  cut,  and  by 
means  of  a  blunt  instrument,  such  as  the  handle  of  a  scalpel, 
the  skin  is  undermined  so  as  to  connect  the  two  openings 
beneath  a  bridg^e  of  skin  and  subcutaneous  tissue.     A  closed 


OPERATIONS  UPON  THE  STOMACH 


257 


pair  of  pressure  forceps  is  introduced  through  the  upper 
incision  as  far  as  the  projecting  part  of  the  stomach,  and 
made  to  grasp  the  most  prominent  part,  which  it  draws  up 
to  and  beyond  the  surface  of  the  second  opening,  where  it  is 
retained  by  means  of  two  hare-hp  pins.  It  should  just  fill 
the  opening,  and  should  require  no  sutures.  The  lower 
opening  is  now  closed  by  two  or  three  silkworm-gut  sutures 


Fig.  53. — Gastrostomy.     (Frank's  Method  Modified.) 


or  by  a  continuous  stitch,  and  the  edges  are  dried  and 
covered  with  collodion  and  gauze.  If  needful,  the  stomach 
can  be  opened  at  once  by  a  tenotomy  knife  introduced 
between  the  pins ;  but,  if  possible,  the  opening  should  be 
deferred  for  twenty-four  hours,  when  a  barrier  of  lymph  will 
have  been  thrown  out.  After  opening  the  stomach,  a  soft 
catheter,  from  a  No.  8  to  No.  12,  is  inserted,  to  which  a 
piece  of  tubing  is  fixed,  and  by  means  of  a  funnel  the  patient 

17 


258 


SURGERY  OF  THE  STOMACH 


can  at  once  be  fed  with  warm  milk  and  egg,  or  whatever 
liquid  may  be  thought  desirable.  The  catheter  may  be  left 
in  position  for  a  few  days,  after  which  it  is  easy  to  insert  it 
whenever  a  meal  is  required. 

2.  Senn's  Method  {Jotirn.  Anier.  Med.  Assoc,  1896). — 
The  stomach  being  exposed,  an  incision  about  ^  inch  in 
length  is  made  into  its  cavity  as  near  the  cardia  as  possible, 


Fig.  54. — Gastrostomy.     (Frank's  Method  Modified.) 


and  midway  between  the  greater  and  lesser  curvatures.  A 
tube  equal  to  a  No.  12  or  14  catheter  is  now  introduced  into 
the  stomach,  and  there  fixed  by  a  suture,  which  includes  the 
cut  edge  of  the  stomach  and  the  side  of  the  tube.  In  order 
to  infold  the  tube  in  the  stomach  wall,  a  purse-string  suture 
is  passed  round  the  tube  at  a  distance  of  h  inch  from  it.  The 
tube  is  pushed  inwards  towards  the  stomach  cavity  while 
the  suture  is  tied.  A  second  purse-string  suture,  and  then  a 
third,  are  passed  and  tied  in  the  same  manner.     The  result  is 


OPERATIONS  UPON  THE  STOMACH  259 

that  the  tube  hes  in  a  funnel-shaped  inverted  portion  of  the 
anterior  wall  of  the  stomach,  and  is  there  fixed  by  the  sutures 
placed  one  above  the  other.  The  stomach  is  now  fixed  to 
the  anterior  abdominal  wall  by  a  suture  above  and  a  suture 
below  the  tube,  and  the  abdominal  incision  is  closed  in  the 
usual  manner.  The  advantage  of  this  method  over  Frank's 
lies  in  the  fact  that,  as  the  portion  of  the  anterior  stomach 
wall  used  for  the  purpose  of  effecting  a  valvular  action  is 
pushed  inwards  instead  of  being  dragged  outwards,  a  larger 
cavity  is  left  for  the  reception  of  food,  and  the  area  of  the 
gastric  mucosa  brought  into  contact  with  the  food  is  there- 
fore more  extensive. 

3.  "Witzel's  Method  {Cent,  fiir  Chir.,  1891).  —  Fenger's 
incision,  parallel  to  the  costal  margin,  is  made  until  the 
rectus  muscle  is  reached.  The  fibres  of  the  muscle  are  split 
vertically,  and  the  peritoneum  opened.  The  stomach  is 
exposed  and  drawn  out  of  the  wound ;  a  small  incision  is 
made  into  the  stomach,  a  tube  introduced  and  fixed  by  a 
single  catgut  suture.  The  tube  is  then  laid  upon  the 
stomach  wall  for  a  distance  of  2  inches  or  rather  more,  and 
a  gutter  is  made  for  it  by  raising  up  a  fold  on  each  side  and 
stitching  the  folds  over  the  tube.  The  tube  then  opens  into 
the  stomach  '  in  the  same  manner  as  the  ureter  opens  into 
the  bladder.'  The  stomach  is  fixed  to  the  abdominal  wall 
by  two  or  three  sutures.  Mikulicz  and  Helferich  have 
shown  that  after  the  lapse  of  a  few  months  the  oblique 
passage  for  the  tube  becomes  a  direct  one,  the  inner  orifice 
lying  behind  the  outer. 

4.  Kader's  Method  {Cent,  fur  Chir.,  1896). — The  stomach  is 
exposed  through  Fenger's  incision,  a  cut  is  made  into  it, 
and  a  tube  introduced  and  fixed  by  a  single  catgut  stitch. 
Two  parallel  folds  of  the  stomach  are  then  raised  up,  one  on 
each  side  of  the  tube,  and  their  summits  are  sutured  by  two 
or  three  Lembert's  sutures  above,  and  the  same  number 
below,  the  tube.  The  sutures  are  cut  short.  Two  similar 
parallel  folds  are  again  raised  up  and  again  stitched,  and,  if 
necessary,  a  third  tier  is  added.  A  most  efficient  valve  is 
thus  formed.  The  stomach  is  fixed  by  one  or  two  sutures  to 
the  anterior  abdominal  wall. 

17 — 2 


26o  SURGERY  OF  THE  STOMACH 

In  the  three  last  methods  a  tube,  closed  by  a  clip  or 
a  safety-pin,  should  always  be  kept  in  the  stomach,  as  the 
openings  so  readily  contract. 

The  following  is  a  complete  list  of  our  cases  of  gas- 
trostomy : 


Fig.  55..— Gastrostomy.     (Witzel's  Method.) 

Case  i. — Mr.  J.  F.,  aged  fifty.  Seen  at  infirmary.  Cancer  of 
oesophagus.  Very  feeble.  Operation  March  24,  1884.  Died 
fifth  day. 

Case  2. — Mr.  C.  L.,  aged  fifty-three.  Seen  at  infirmary. 
Cancer  of  oesophagus.  Operation  April  25,  18S4.  Died  seventh 
day. 

Case  3. — Mrs.  A.  D.,  aged  fifty-one.  Seen  at  infirmary. 
Cancer  of  oesophagus.  Operation  August  ig,  1885.  Died 
seventh  day. 


OPERATIONS  UPON  THE  STOMACH  261 

Case  4. — Mr.  T.  O.,  aged  fifty-one.  Seen  at  infirmary.  Five 
months'  symptoms.  Cancer  of  cesophagus.  Operation  May  30, 
i88g.  Recovery.  Gained  ih  stones.  Lived  a  year  and  three 
months. 


Fig.  56. — Gastrostomy.     (Kader's  Method.) 


Fig.  57.— Gastrostomy.     (Kader's  Method.) 

Case    5. — Mr.   D.   P.,   aged    sixty-four.      Seen    at  infirmary. 

Cancer  of  oesophagus.  Patient  almost  moribund.  Operation 
November  7,  1894.    Died  second  day. 

Case  6. — Miss   F.  W.,  aged  forty-six.     Seen  with  Dr.  Hick. 


262  SURGERY  OF  THE  STOMACH 

Malignant  disease  high  in  oesophagus.  Operation  February  2, 
1895  (Greig  Smith's  method).  Tracheotomy  necessary  also. 
Lived  five  months. 

Case  7. — Mr.  W.  H.,  of  Burnley,  aged  forty-eight.  Seen  at 
infirmary.  Dysphagia.  Loss  of  weight  from  g  stones  10  pounds 
to  7  stones  13  pounds  in  six  months.  Operation  September  10, 
1895.     Recovery.     Living  a  year  later. 

Case  8. — Mr.  W.  B.,  aged  sixty-four.  Seen  at  infirmary. 
Cancer  of  oesophagus.     Operation  May  15,  i8g6.     Died  fifth  day. 

Case  9. — Mrs.  E.  H.,  aged  forty-three.  Seen  at  infirmary. 
Cancer  of  pharynx.  Operation  October  3,  1896  (modification 
of  Frank's  method).  Recovery.  Lived  two  months,  and  had 
tracheotomy  for  cancer  of  larynx. 

Case  10. — Mr.  C.  N.,  of  Brighouse,  aged  fifty-eight.  Seen  at 
infirmary.  Dysphagia  two  months.  Hoarseness  two  months. 
Operation  January  28, 1897.    Recovery.    Out-patient  February  16. 

Case  ii. — Mr.  M.,  aged  fifty-seven.  Seen  with  Dr.  Herbert 
Robson.  Cancer  of  pharynx.  Inability  to  swallow.  Operation 
April  24,  1897.  Recovery.  Lived  some  months,  and  had 
tracheotomy  done  June  11,  1897. 

Case  12. — Mrs.  G.  L.,  aged  thirty-two.  Seen  at  infirmary. 
Dysphagia  two  years.  Weight  6  stones.  Operation  July  16, 
1897.     Recovery.     Out-patient  August  6. 

Case  13. — Mrs.  B.  W.,  aged  fifty.  Seen  at  infirmary. 
Dysphagia  seven  months.  Lost  5  stones.  Operation  June  3, 
1897.     Recovery.     Out-patient  June  11  at  own  request. 

Case  14. — Mr.  F.,  aged  forty-nine.  Seen  with  Dr.  Carter, 
Starbeck.  Cancer  of  oesophagus.  Dysphagia  11  months. 
Operation  January  18,  1898.     Recovery.     Lived  several  months. 

Case  15. — Mr.  J.,  aged  forty-eight.  Seen  with  Dr.  Marshall 
of  Halifax.  Cancer  of  oesophagus.  Operation  October  25,  1898. 
Recovery. 

Case  16. — Mr.  W.  H.,  aged  sixty-six.  Seen  with  Dr.  Milne 
of  ]\Iirfield.  Operation  September  8,  1899  (Frank's  method). 
Carcinoma  near  cardia.     Died  November,  1900. 

Case  17. — Mrs.  F.  A.  R.,  aged  sixty-three.  Seen  at  infirmary. 
Carcinoma  near  cardia.  Operation  September  19,  1899  (Kader's 
method).  Recovery.  Seen  eight  and  a  half  months  later.  Since 
lost  sight  of. 

Case  18. — Mrs.  E.  B.,  aged  fifty-two.  Seen  at  infirmary. 
Carcinoma  near  cardia.  Operation  September  20,  1899  (Kader's 
method).     Almost  moribund.     Lived  twenty-two  days. 

Case  19. — Mr.  B.,  aged  eighty-six.  Seen  with  Dr.  Bevan 
Lewis  of  Wakefield.  Three  years'  history  of  dysphagia. 
Operation  October  19,  1899.     (Cocaine  anaesthesia.)     Recovery. 


OPERATIONS  UPON  THE  STOMACH  263 

Case  20. — Mrs.  B,,  aged  fifty-three.  Seen  with  Dr.  Sharpe  of 
Matlock.  Stricture  of  oesophagus.  Operation  March  29,  igoo. 
Recovery.  Before  leaving  home  gained  5  pounds  ;  later  consider- 
able gain  in  weight.     Living  a  year  later,  and  said  to  be  well. 

Case  21. — Mrs.  N.  P.,  aged  forty-two.  Seen  at  infirmary. 
Eight  months'  dysphagia.  Lost  i  stone  between  February  and 
April.  Operation  April  10,  1900,  Recovery.  Out-patient 
June  15. 

Case  22. — Mr.  C.  T.,  aged  fifty-one.  Seen  with  Dr.  Tyrie. 
Carcinoma  near  cardia.  Operation  June  14,  igoo  (Senn's 
method).     Recovery. 

Case  23. — Mr.  G.  S.,  aged  fifty.  Seen  at  infirmary.  Carci- 
noma lower  end  of  oesophagus.  Operation  August  6,  1900 
(Senn's  method).     Recovery.     Still  living. 

Case  24. — Mrs.  E.  H.,  aged  fifty-six.  Seen  at  infirmary. 
Carcinoma  low^er  end  of  oesophagus.  Operation  September  17, 
1900  (Senn's  method).     Recovery.     Still  living. 

Case  25. — Mr.  P.,  aged  fifty-four.  Seen  with  Dr.  Knight  of 
Keswuck.  Stricture  of  oesophagus.  Four  months'  dysphagia. 
Operation  April  4,  1901.     Recovery. 

Case  26. — Mrs.  H.,  aged  fifty-five.  Seen  with  Dr.  Home, 
Barnsley.  Extreme  weakness.  Cancer  of  cardiac  orifice  of 
stomach.     Operation  April  15,  1901.     Recovery. 

From  this  list  it  will  be  seen  that  since  January,  1897,  we  have 
had  no  death  from  the  operation.     Total — 26  cases,  5  deaths. 


Pyloroplasty. 

Pyloroplasty  was  first  performed  in  1886  by  Heineke,  in 
1887  by  Mikulicz.  The  stomach  being  exposed,  the  pylorus 
is  drawn  into  the  wound  and  protected  well  with  sponges. 
The  stricture  is  then  divided  transversely  by  an  incision 
which  must  extend  at  the  least  i  inch  on  each  side  of  it. 
This  incision  may  be  commenced  from  the  stomach  side, 
and  prolonged  towards  and  into  the  duodenum  either  by 
scissors  or  by  a  scalpel  guided  along  a  director  passed 
through  the  constriction.  Nibbed  forceps  are  then  applied 
to  the  middle  of  the  upper  and  lower  lips  of  the  incision. 
On  pulling  these  upwards  and  downwards  the  transverse 
incision  becomes  longitudinal,  and  in  this  position  it  is 
sutured.  Two  layers  of  stitches  are  applied,  both  con- 
tinuous.     The  mucous  membrane  is  stitched  with  catgut, 


264  SURGERY  OF  THE  STOMACH 

and  the  peritoneum  with  silk  or  celluloid  thread.  The 
operation  ma}-  be  modified  by  introducing  a  bone  bobbin  as 
an  internal  splint,  and  suturing  over  this. 

The  important  point  in  the  operation,  necessary  for 
success,  is  the  making  of  the  dividing  cut  of  ample  length. 
As  our  experience  of  pyloroplasty  increases,  we  are  inclined 
to  place  less  reliance  upon  it  as  a  therapeutic  measure.  In 
certain  of  our  own  cases,  and  in  those  of  our  colleagues, 
cases  which  have  been  brilliantly  successful  in  their  im- 
mediate results  have  shown  after  the  lapse  of  eighteen 
months,  two  years,  or  longer,  a  tendency  to  relapse.  In 
none  of  the  cases  has  there  been  a  complete  return  to  the 
original  condition,  but  symptoms  of  the  same  kind,  though 
less  in  degree,  have  been  observed. 

Pyloroplasty  must  not  be  performed  where  there  is  active 
ulceration  or  moderate  or  extensive  induration,  or  adhesions 
the  result  of  peripyloritis.  In  those  cases  where  narrowing 
of  the  outlet  occurs  after  pyloroplasty  it  is  probable  that  the 
operation  has  been  contra-indicated  from  the  first,  though 
experience  to  guide  us  at  the  time  was  lacking.  As  the 
prohibitive  restrictions  we  have  mentioned  are  present  in  the 
majority  of  cases,  it  necessarily  follows  that  the  role  of 
pyloroplasty  is  a  limited  one.  Though  this  opinion  is  con- 
trary to  that  of  many  surgeons,  we  feel  convinced  that  it  will 
be  shared  by  all  who  can  watch  for  years  the  careers  of  their 
patients.  Berg  {British  Medical  Jotmial,  August,  igoo)  has 
abandoned  pyloroplasty  for  gastro-enterostomy  in  cases  of 
pyloric  stenosis  on  account  of  this  tendency  to  recurrence  of 
the  stricture.  Pyloroplasty  will  be  chiefly  of  service  in  cases 
of  string-like  narrowing  or  in  spasm  of  the  pylorus. 


Gastroplasty. 

Gastroplasty  was  first  performed  by  Wolfler  in  1894  for 
hour-glass  stomach.  The  operation  tallies  in  all  its  details 
with  pyloroplasty.  The  incision  dividing  the  isthmus  should 
be  of  a  minimum  length  of  3I  to  4  inches.  Illustrative 
cases  are  mentioned  in  the  chapter  dealing  with  Hour-glass 
Stomach. 


OPERATIONS  UPON  THE  STOMACH 


265 


Gastro-gastrostomy,  or  Gastro-anastomosis. 

This  operation  was  first  performed  by  Wolfler.  A  modi- 
fication of  the  original  procedure  was  adopted  by  Francis 
S.  Watson  in  1895. 


Fig.  58.— Pyloroplasty. 


The   operation   is    suited   to    those    cases    of    hour-glass 
stomach  in  which  the  sagging  of  the  stomach  on  each  side 


266 


SURGERY  OF  THE  STOMACH 


of  the  constriction  permits  of  an  anastomotic  opening  being 
made  in  each  complement  of  the  stomach. 

The  stomach  being  isolated  by  means  of  sponges  or  gauze, 
the  contiguous  sides  of  the  two  halves  of  the  stomach  are 
placed  in  apposition.  Into  each  cavity  a  vertical  incision  is 
made  of  the  greatest  length  possible.  The  incision  should 
extend  from  just  below  the  constriction  to  the  greater  curva- 
ture of  the  stomach,  and  is  carried  through  the  serous  and 
muscular  coats  until  the  mucous  membrane  bulges  outwards. 


Fig.  59. — Gastroplasty  with  the  aid  of  Mayo  Robson's  Bobbin. 

An  ellipse  of  mucous  membrane  is  then  removed  as  advised 
by  Moynihan  in  gastro-enterostomy.  Bleeding  is  free  and 
occurs  from  many  points. 

The  two  openings  are  now  united  by  continuous  sutures, 
an  outer  of  silk  or  celluloid  thread  for  the  serous  coat,  and 
an  inner  of  catgut  for  the  mucous  coat,  or  for  the  whole 
thickness  of  the  stomach  wall — preferably  the  latter. 

The  largest-sized  bone  bobbin  may  be  introduced  as  an 
internal  splint  whereon  to  stitch. 

Watson"s    Method.  —  This    operation    is   described    by   its 


OPERATIONS  UPON  THE  STOMACH  267 

originator  in  the  Annals  of  Surgery,  July,  1900.  The  steps 
of  the  operation  were  as  follows:  The  pyloric  portion  was 
raised  and  turned  over  on  to  the  cardiac,  the  constriction 
being  used  as  a  hinge,  thus  making  it,  the  hitherto  injurious 
feature,  become  a  useful  technical  agent.  The  next  step 
consisted  in  uniting  the  two  parts  of  the  stomach  to  each 
other  in  the  position  just  described  and  previous  to  making 
the  communicating  opening,  the  object  being  to  defer  doing 
the  latter  until  the  end  of  the  operation,  in  order  to  avoid 
spilling  the  stomach  contents  into  the  peritoneal  cavity.  This 
union  was  accomplished  by  means  of  a  single  line  of  fine 
silk  sutures  passed  through  the  serous  and  muscular  coats  of 
the  two  halves  of  the  organ,  and  uniting  them  by  a  portion 
of  their  surfaces,  having  an  elliptical  form  and  measuring 
3|-  inches  in  length  by  about  It  inches  in  width.  One  suture 
was  left  long  at  each  side  of  the  two  ends  of  the  ellipse  in 
order  that  the  limits  of  the  sutured  area  might  be  defined  by 
traction  upon  them  at  the  moment  of  making  the  communi- 
cating openings,  as  will  be  seen  later.  The  two  compart- 
ments of  the  stomach  being  thus  attached  to  each  other, 
there  remained  but  one  way  to  gain  access  to  that  part  of 
their  surfaces  which  was  held  in  apposition  within  the  ellip- 
tical line  of  sutures,  and  through  which  the  communicating 
openings  must  be  made,  and  that  way  was  through  the 
presenting  surface — the  roof,  so  to  speak — of  the  pyloric 
compartment.  This  was  accordingly  done  by  a  short  in- 
cision through  that  part.  The  edges  of  this  incision  being 
held  up  by  tenacula  and  the  contents  of  the  pyloric  chamber 
being  sponged  out,  there  was  no  soiling  of  the  peritoneum 
by  it.  Traction  was  now  made  on  the  four  long  sutures, 
and  the  length  and  breadth  of  the  sutured  ellipse  was 
thereby  at  once  defined,  and  its  surface  was,  moreover,  made 
tense.  A  scalpel  was  passed  through  the  walls  of  both 
chambers  of  the  stomach  at  a  point  close  to  one  end  of  the 
ellipse  and  carried  to  its  opposite  end,  thereby  establishing 
communicating  openings  between  the  two  halves  of  the 
stomach  by  incisions  through  the  walls  of  both,  which 
incisions,  being  made  by  one  and  the  same  stroke  of  the 
knife,  necessarily  corresponded  exactly  in  all  respects.     The 


268  SURGERY  OF  THE  STOMACH 

cuts  lay  in  the  direction  of  the  long  axis  of  the  stomach, 
midway  between  its  greater  and  lesser  curvatures,  and  were 
about  3  inches  long.  A  widely-spaced  buttonhole  suture 
was  applied  over  the  edges  of  the  incisions,  to  avoid  their 
opposite  sides  uniting.  Closure  of  the  w^ound  in  the  roof  of 
the  pyloric  half  of  the  stomach  completed  the  operation. 

The  advantages  of  this  method  over  Wolfler's  are  not 
apparent,  and,  as  it  is  more  cumbersome  and  takes  longer  in 
the  doing,  we  do  not  counsel  its  adoption. 


Gastro-enterostomy. 

In  this  operation  an  anastomosis  is  made  between  the 
stomach  and  the  small  intestine.  It  was  first  suggested  by 
Nicoladoni  in  1881. 

Gastro-enterostomy  may  be  performed  in  one  of  two  ways. 
The  jejunum  (the  portion  of  bowel  usually  selected)  may  be 
joined  either  to  the  anterior  (Wolfler's  method)  or  to  the 
posterior  (Von  Hacker's  method)  wall  of  the  stomach. 

Each  operation  has  its  own  advocates.  We  have  more 
frequently  and  latterly  adopted  the  posterior  operation. 
Mikulicz,  whose  experience  is  considerable,  has  abandoned 
the  posterior  method  for  the  anterior,  w^hile  Carle  in  malig- 
nant cases  has  abandoned  the  anterior  for  the  posterior. 
The  chief  advantage  of  the  posterior  over  the  anterior  is 
claimed  to  be  that  the  opening  is  at  a  more  dependent 
portion  of  the  stomach,  and  therefore,  while  the  patient  lies 
upon  his  back  in  bed  after  the  operation,  the  stomach 
contents  will  the  more  readily  drain  into  the  intestine. 
When  the  junction  is  made  on  the  anterior  surface,  how- 
ever, the  traction  of  the  lesser  bowel  brings  the  anastomosis 
to  the  lowest  point  of  the  stomach,  as  may  be  seen  after 
the  viscera  are  replaced,  or  especially  when  the  parts  are 
examined,  if  death  follows  some  weeks  or  months  after  the 
operation.  Under  such  circumstances,  the  opening  is  seen 
to  be  at  the  apex  of  a  funnel-shaped  portion  of  the  stomach. 
It  is  said  that  regurgitation  of  bile  and  pancreatic  juice  is 
less  likely  to  occur  after  the  posterior  operation,  but  the 
evidence  on  this  point  is  not  satisfactory.     It  is  now  proved 


OPERATIONS  UPON  THE  STOMACH  269 

beyond  question  that  in  all  cases  of  gastro-enterostomy  a 
regurgitation  of  these  juices  into  the  stomach  occurs  con- 
stantly. Neither  secretion  in  the  least  affects  the  digestion 
of  food,  as  has  been  shown  by  Dastre,  Oddi,  Moynihan,  and 
others. 

Our  own  decided  preference  is  for  the  posterior  operation. 
In  our  earlier  cases  we  both  adopted  the  anterior  method, 
but  our  later  operations  have  all  been  carried  out  by  Von 
Hacker's  method,  and  the  results  have  been  excellent. 
Sickness  after  the  first  few  hours  is  almost  unknown,  having 
only  occurred  to  a  trivial  extent  in  two  cases.  In  feeble 
patients  with  a  tendency  to  hypostatic  changes  in  the  lungs 
the  bed-rest  may  be  allowed  from  the  first. 

Technique. — The  abdomen  is  opened  by  an  incision  4  inches 
long  in  the  middle  line,  or  near  it,  above  the  umbilicus.  The 
stomach  is  thus  exposed.  The  jejunum  is  readily  found  by 
turning  the  omentum  and  transverse  colon  upwards,  locating 
the  inferior  duodenal  fold  or  the  last  portion  of  the  duo- 
denum, and  so  seizing  the  first  portion  of  the  jejunum. 
A  point  about  12  inches  from  the  duodeno-jejunal  angle  is 
chosen  for  the  anastomosis  in  the  anterior  operation,  less  than 
this  for  the  posterior  operation.  A  loop  is  drawn  out,  milked 
until  empty,  and  encircled  with  an  elastic  ligature,  care  being 
taken  that  the  proximal  end  of  the  loop  is  towards  the 
cardiac  end  of  the  stomach.  The  union  of  the  viscera  can 
be  effected  outside  the  abdomen,  sponges  or  strips  of  gauze 
being  packed  round  to  isolate  the  operation  area.  In  the 
anterior  operation  the  point  selected  on  the  stomach  for  the 
incision  is  near  the  pylorus,  and  as  close  to  the  greater 
curvature  as  possible.  After  the  suture  of  the  two  orifices  is 
complete,  a  few  additional  stitches  are  introduced  into  the 
proximal  end  of  the  loop,  securing  it  at  a  higher  level  on  the 
stomach  wall  and  into  the  distal,  and  securing  it  at  a  lower 
level,  in  order  to  obviate  kinking.  In  the  posterior  operation 
the  transverse  colon  and  great  omentum  are  pulled  upwards, 
exposing  the  under-surface  of  the  transverse  mesocolon,  A 
small  slit  is  made  in  this  antero-posteriorly,  and  enlarged  with 
the  fingers,  care  being  taken  scrupulously  to  avoid  the  wound- 
ing of  any  vessel.     The  posterior  wall  of  the  stomach  is  thus 


>7o 


SURGERY  OF  THE  STOMACH 


exposed,  and  may  be  held  in  position  by  the  pressure  of  an 
assistant's  hand  from  above.  The  lateral  margins  of  the 
incision  in  the  transverse  mesocolon  are  stitched  on  each  side 
to  the  stomach  by  a  single  suture,  in  order  to  prevent  closure 
of  the  slit  and  consequent  narrowing  of  the  jejunum,  as 
noticed  by  Czerny.  The  union  of  the  viscera  may  be  effected 
in  both  anterior  and  posterior  operations  in  one  of  three 
ways  : 


Fig.  6o.—  Anterior  Gastro-eNterostomy. 


1.  By  simple  suture. 

2.  By  Robson's  bobbin. 

3.  By  Murphy's  button. 

The  suture  employed  in  i  and  2  is  practically  the  same. 
The  bobbin  is  used  as  a  splint  upon  which  the  stitches  may 
be  tightly  pulled.  By  its  use  an  opening  of  a  known  size  is 
immediately  secured.  Murphy's  button  is  generally  used 
only  when  the  greatest  haste  is  desirable.  As  the  stitching 
in  either  of  the  two  former  methods  can  be  done  in  from 
four  to  eight  minutes  by  practised  hands,  the  button  is  rarely, 


OPERATIONS  UPON  THE  STOMACH 


271 


if  ever,  necessary.  Mikulicz  regularly  employs  it,  and  speaks 
well  of  it,  and  many  other  surgeons  prefer  its  use  to  all  other 
methods.  If,  however,  its  one  advantage,  rapidity,  is  nega- 
tived by  the  operator  having  accustomed  himself  to  the  details 
of  simple  suture,  the  button  can  only  be  harmful. 

Method   of  Stitching.  —  The  stomach  and   intestine  being 
placed  in  apposition,  a  continuous  Lembert  stitch  of  silk,  or 


Fig.  61. 


-Posterior  Gastro-enterostomy  with  the  aid  of  Mayo 
Robson's  Bone  Bobbin. 


Pagenstecher  thread,  unites  the  serous  surfaces  for  a  distance 
of  2  inches  or  more.  The  line  of  this  stitch  is  semi-oval, 
and  unites  the  posterior  surfaces  of  the  anastomotic  opening. 
Incisions  are  then  made  into  the  viscera  in  front  of  the 
suture.  A  second  suture  is  now  passed,  uniting  the  posterior 
cut  edges ;  this  may  take  only  the  mucous  membrane,  or  all 
the  coats,  and  is  of  catgut.  After  completing  the  posterior 
half,  the  bobbin  (if  one  is  used)  is  introduced.     The  anterior 


272 


SURGERY  OF  THE  STOMACH 


layers  of  stitches  are  now  completed,  first  the  cut  edges  and 
then  the  serous  coats,  in  precisely  the  same  fashion  as  the 
posterior.  If  the  bobbin  is  used,  the  sutures  are  drawn  tight 
on  to  it  in  tying.  If  not,  the  stitch  must  be  interrupted  at 
one  point  or  more  (one  point  is  sufficient)  in  order  to  prevent 
the  suture  '  drawing  '  and  puckering  the  orifice. 

Murphy's  Button.  —  The  purse-string   suture   usually   em- 


FiG.  62. — Posterior  Gastro-enterostomy.     Simple  Suture. 


ployed  is  unnecessarily  cumbersome,  and  probably  harmful, 
puckering  up  the  coats  of  the  gut  around  the  central  tube, 
and  preventing  accurate  fitting  of  the  opposed  serous 
surfaces  when  the  button  is  closed.  The  better  method  is 
to  make  a  small  incision  into  the  viscus,  introduce  the  half- 
button,  and  stitch  up  the  incision  by  one  or  two  Lembert 
sutures  until  the  cylinder  is  tightly  gripped.  If  the  stitches 
are  to  the  left  of  the  button  in  the  stomach,  they  may  be 


OPERATIONS  UPON  THE  STOMACH  273 

with  advantage  put  to  the  right  in  the  jejunum,  in  order  to 
secure  perfect  accuracy  of  serous  coaptation.  Though 
Murphy's  button  enables  a  rapid  and  effective  anastomosis 
to  be  made,  the  remote  dangers  are  not  inconsiderable.  We 
hardly  think  it  likely  that  we  shall  ever  use  it  again  in  per- 
forming gastro-enterostomy. 

Removal  of  Mucous  Membrane. — Chlumskij,  in  reporting 
from  the  clinic  of  Mikulicz  the  results  of  ten  post-mortem 
examinations  performed  upon  cases  of  gastro-enterostomy  in 
which  the  simple  suture  had  been  used,  found  that  in  all  the 
opening  was  not  of  adequate  size.  This  lessening  in  the  size 
of  the  opening  may  be  due  either  to  cicatricial  contraction  or 
to  thickening  and  pouting  of  the  mucous  membrane  at  the 
orifice.  Kelling  {Archiv.  f.  Klin.  Chir.,  Bd.  62)  states  that 
the  chief  advantage  of  the  Murphy  button  over  simple  suture 
is  the  prevention  of  the  formation  of  a  ring  of  mucous  mem- 
brane which  projects  into  the  stomach  and  occludes  the  new 
opening.  To  avoid  this,  it  will  be  found  helpful  to  remove  a 
small  portion  of  the  mucous  membrane  of  each  viscus.  This 
may  be  done  in  the  following  manner  :  When  incising  the 
gut,  the  serous  and  subserous  layer  are  cut  through  carefully. 
The  mucous  membrane  then  bulges  into  the  wound,  is  seized 
with  nipped  forceps,  loosened  on  each  side  from  the  sub- 
mucous coat,  and  an  ellipse  of  it  as  long  as  the  wound  and 
f  inch  broad  is  cut  away.  This  procedure  has  been  followed 
by  Moynihan  during  the  last  eighteen  months,  and  has  given 
eminently  satisfactory  results.  A  very  simple  and  efficient 
method  of  performing  gastro-enterostomy,  and  other  intes- 
tinal anastomoses  in  which  removal  of  the  mucous  mem- 
brane is  an  essential  feature,  is  described  by  Littlewood 
{Lancet,  November,  igoo). 


Gastro-duodenostomy. 

This  operation  was  first  suggested  in  1892  by  Jaboulay,  and 
performed  by  him  in  1894.  ^^  has  since  related  four  cases, 
three  of  them  successful.  The  operation  has  been  warmly 
approved  by  Mikulicz  and  \'illard.     The  anastomosis  is  made 

iS 


274  SURGERY  OF  THE  STOMACH 

between  the  pyloric  end  of  the  stomach  and  the  anterior 
surface  of  the  duodenum.  Each  viscus  is  opened  by  a 
vertical  incision,  and  union  may  be  effected  either  by  the 
bobbin  or  by  simple  suture.  The  operation  is  most  easily 
performed  when  there  is  a  largely  dilated  stomach  and  a 
mobile  duodenum.  In  one  case  reported  by  Spencer,  any 
other  gastro-intestinal  anastomosis  was  impossible  by  reason 
of  extensive  adhesions  which  affected  all  but  the  pyloric 
portion  of  the  stomach.  When  the  pyloric  region  is  adherent 
or  invaded  by  growth  the  operation  is  impossible. 

The  advantages  of  this  procedure  over  gastro-jejunostomy 
are  claimed  to  be,  the  easier  emptying  of  the  stomach  at  an 
orifice  near  the  natural  outlet,  and  the  absence  of  bile  re- 
gurgitation owing  to  the  fact  that  the  new  opening  in  the 
intestine  is  placed  above  the  bile-papilla.  We  have  adopted 
the  method  in  one  instance  only,  but  we  feel  that  it  is  one 
that  may  be  more  frequently  adopted  with  advantage. 


After  Effects  of  G-astro-enterostomy.. 

I,  Regurgitant  Vomiting  has  been  very  much  more  fre- 
quently observed  in  malignant  than  in  simple  disease.  The 
cause  of  it  is  difficult  to  determine.  In  some  cases,  as  in 
those  of  Mikulicz,  it  is  apparently  due  to  spur-formation  at 
the  new  orifice,  of  such  a  kind  as  to  determine  the  flow  of  the 
intestinal  contents  into  the  stomach,  rather  than  in  the  reverse 
-direction.  At  times  the  vomiting  is  trivial,  occurring  but 
.once  or  twice  ;  at  times,  again,  it  is  most  serious,  and  hastens 
or  determines  death.  It  may  be  dealt  with  most  satis- 
factorily by  occasional  or  frequent  lavage  (as  seems  neces- 
sary) and  by  abstinence  from  mouth-feeding.  The  vomit  in 
the  beginning  is  in  appearance  chiefly  composed  of  bile,  and 
it  was  to  the  presence  of  bile  in  the  stomach  that  the 
vomiting  was  attributed.  Riegel,  Malbranc  and  Weil  have 
related  cases  where  a  reflux  of  bile  into  the  stomach  resulted 
in  grave  symptoms.  Billroth  remarked  upon  the  serious 
import  of  bile  regurgitation  after  gastro-enterostomy.  Claude 
-Bernard  and  others,  founding  their  opinion  upon  laboratory 


OPERATIONS  UPON  THE  STOMACH  275 

work,  considered  that  bile  inhibited  gastric  digestion.  Dastre, 
in  dogs  with  gastric  fistulse,  introduced  bile  at  all  stages  of 
digestion,  and  concluded  that  the  alkalinizing  effect  of  the 
bile  was  swiftly  negatived  by  a  copious  outflow  of  gastric 
juice.  No  ill-effects  were  noticed  either  in  the  digestive 
powers  or  in  the  general  health.  Oddi,  experimenting  upon 
dogs,  obliterated  the  common  bile-duct  and  united  the  gall- 
bladder to  the  stomach.  All  the  bile  consequently  flowed  at 
once  into  the  stomach,  with  the  result  that  the  animals 
gained  in  weight  and  suffered  not  at  all.  Max  Wickhoff, 
Angelberger  and  Terrier  have  performed  cholecysto-gas- 
trostomy  for  obstruction  in  the  common  bile-duct.  These 
observations  all  show  that  the  mere  presence  of  bile  alone  is 
insufficient  to  induce  vomiting.  Chlumskij  has  suggested 
that  it  is  the  presence  of  pancreatic  juice  which  so  irritates 
the  stomach  as  to  make  it  reject  all  fluids.  But  this  theory 
is  negatived  by  Steudel's  experiments  upon  dogs  and  by 
Moynihan's  case,  in  which,  owing  to  a  complete  severance 
of  the  gut  at  the  duodeno-jejunal  junction,  the  duodenum 
was  stitched  up  completely,  and  the  open  end  of  the  jejunum 
implanted  in  the  anterior  wall  of  the  stomach  {British 
Medical  Journal,  May,  igoi).  In  this  case  all  the  bile  and 
all  the  pancreatic  juice  passed  into  the  stomach,  yet  digestion 
was  active  and  complete,  and  vomiting  was  absent.  More- 
over, Hartmann  and  Soupault  have  recently  shown  that  in 
all  cases  of  gastro-enterostomy,  whether  anterior  or  posterior, 
there  is  a  reflux  of  bile  and  of  pancreatic  juice  into  the 
stomach.  Carle  and  Fantino,  Hayem,  Mathieu  and  others, 
have  made  the  same  observation.  The  cause,  then,  of 
regurgitant  vomiting  is  not  understood.  Numerous  '  com- 
plementary operations '  have  been  suggested  in  order  to 
prevent  it.  Doyen  cuts  the  intestine  across,  implants  the 
distal  end  into  the  stomach  and  the  proximal  into  the  side  of 
the  distal,  and  thus  avoids  the  '  circulus  vitiosus.'  Jaboulay, 
Braun  and  Weir  advise  a  side-to-side  approximation  of  the 
proximal  and  distal  loops. 

2.  Subsequent  Contraction  of  the  New  Orifice  between  the 
stomach  and  intestine  must  occur  to  some  extent  in  all  cases 
when  the  dib-tation  of  the  stomach,  present  at  the  operation,. 

18—2 


276  SURGERY  OF  THE  STOMACH 

undergoes  progressive  diminution.  Moynihan  has  recorded 
one  case  in  which  he  performed  a  second  operation  for 
closure  of  the  orifice,  made  with  the  help  of  Laplace's 
forceps,  and  has  operated  upon  another  in  which  a  colleague 
had,  three  years  previously,  performed  gastro-jejunostomy 
with  the  aid  of  Murphy's  button.  In  this  latter  case  the 
opening  had  completely  closed.  Czerny  records  a  case  where 
the  Murphy  button  was  used,  in  which  the  opening  narrowed 
from  a  diameter  of  5  centimetres  to  8  millimetres.  In  all 
cases  the  anastomosis  should  be  of  wider  calibre  than  seems 
necessary,  in  order  to  avoid  the  risk  of  subsequent  over- 
contraction. 

As  bearing  on  the  closure  of  an  anastomotic  opening, 
Mayo  Robson  found  the  opening  in  a  cholec}'st-enterostomy 
made  by  a  Murphy  button  to  be  closed  three  months  later, 
as  proved  post-mortem,  in  a  case  of  complete  obstruction  of 
the  common  bile-duct. 

W.  H.  Brown  relates  the  following  case  of  closure  of 
an  anastomotic  opening  made  by  Senn's  plates  {Lancet, 
July,  1900)  : 

The  patient,  a  woman,  aged  sixty-two  years,  had  suffered  for 
many  months  from  pain  after  food,  the  pain  gradually  becoming 
most  acute,  so  that  opium  in  full  doses  was  needed  to  obtain  any- 
thing Hke  comfort. 

Latterly,  regular  attacks  of  vomiting  occurred  about  every 
forty-eight  hours,  when  most  of  the  nourishment  taken  during  the 
preceding  two  days  returned. 

No  tumour  could  be  felt,  but  the  symptoms  all  pointed  towards 
pyloric  stenosis.  As  the  condition  of  the  patient  was  getting 
unendurable,  I  decided,  after  consultation  with  Dr.  T.  Churton, 
to  open  the  abdomen  to  see  if  anything  could  be  done.  At  the 
operation  I  found  the  pylorus  greatly  thickened,  and  masses  of 
enlarged  glands  constituting  too  great  an  area  of  disease  to  be 
attacked  with  any  degree  of  safety.  I  therefore  joined  up  a  loop 
of  jejunum  to  the  stomach,  using  Senn's  plates  as  the  scaffold  of 
anastomosis. 

For  the  next  two  weeks  all  went  as  well  as  such  cases  usually 
do,  the  vomiting  ceased,  and  the  pain  gradually  subsided.  At 
the  end  of  that  time,  however,  the  symptoms  of  obstruction  began 
to  reassert  themselves,  the  pain  again  grew  severe,  and  again  the 


OPERATIONS  UPON  THE  STOMACH  277 

regular  vomiting  began,  the  amount  corresponding  with  the 
quantity  of  fluids  taken. 

It  seemed  clear  that  the  new  opening  had,  for  some  reason  or 
other,  ceased  to  be  effectual. 

I  therefore  was  face  to  face  with  a  most  discouraging  chain  of 
events,  and  the  patient  herself  was  as  badly  off  as  she  was  before 
she  submitted  herself  to  operative  interference. 

I  decided  to  act  on  the  assumption  that  the  new  opening 
between  the  stomach  and  the  jejunum  had  closed,  and  determined 
to  reopen  for  the  purpose  of  ascertaining  the  reason.  Accord- 
ingly I  reopened  the  abdomen,  and  I  found  that  the  junction 
between  the  bowel  and  the  stomach  externally  was  quite  satis- 
factory. 

I  then  made  an  incision  into  the  stomach  2  inches  above  the 
junction,  and,  putting  my  finger  inside,  found  that  all  trace  of 
the  bone-plate  had  disappeared,  and  also  that  all  trace  of  the 
opening  was  absent. 

After  a  minute  or  two  I  felt  the  edge  of  the  oyal  cut  of  the 
former  operation,  and,  pressing  firmly  in  the  centre  of  this, 
tore  through  a  membrane  by  which  the  opening  had  been  oc- 
cluded. 

My  finger  then  passed  easily  into  the  bowel,  and  I  stretched 
the  opening  freely  in  all  directions.  I  then  closed  the  exploratory 
incision  into  the  stomach,  and  finished  the  operation  in  the  usual 
manner.  After  a  day'^or  two,  during  which  time  vomiting  was 
incessant,  improvement  set  in. 

The  pain  again  left,  and  it  has  not  since  returned.  The  patient 
is  able  to  take  light  food,  and  the  vomiting  has  ceased. 

She  is  now  out  of  bed  daily,  and  is  gaining  strength.  [This 
patient  is  still  alive  (April,  1901J  and  well.] 

3.  Changes  in  the  Stomach. — If  dilatation,  as  the  result  of 
obstruction,  has  been  present  before  the  gastro-enterostomy, 
a  certain  lessening  in  the  size  of  the  stomach  may  be  expected 
to  occur  as  soon  as  a  fresh  outlet  is  formed.  The  extent  of 
this  lessening  depends  entirely  upon  the  condition  of  the 
muscular  tunic  of  the  stomach.  If  the  stomach  has  dilated 
gradually,  during'  many  months  or  years,  and  if  the  dilata- 
tion has  been  extreme,  there  will  be  little  or  no  rebound,  the 
dilatation  will  undergo  little  or  no  perceptible  diminution. 
On  the  other  hand,  if  dilatation  has  been  rapid  in  its 
oncoming  and  has  never  attained  a  supreme  degree,  the 
return  to  the  normal  size  of  the  stomach  will  be  almost,  or 


278  SURGERY  OF  THE  STOMACH 

wholly,  complete.  In  cancer  of  the  stomach,  or  in  trauma 
resulting  from  swallowing  acids,  etc.  (Terrier  and  Hartmann), 
where  the  latter  conditions  are  fulfilled,  the  stomach  rapidly 
reduces  in  size  after  operation  ;  in  simple  stenosis,  where  the 
former  conditions  are  found,  the  return  is  always  trivial,  if, 
indeed,  there  be  any  return  at  all.  The  motor  insufficiency  of 
the  stomach  is,  according  to  Hartmann  and  Soupault,  a 
permanent  matter,  A  return  to  the  normal  was  never 
observed  in  any  of  their  cases,  even  when  the  examination 
was  made  after  one  year.  Gastric  digestion  is  prolonged 
beyond  the  normal  limits.  Mintz  and  Rosenheim  have 
shown  that  there  is  a  marked  delay  in  the  evacuation  of  the 
stomach  contents.  Carle  and  Fantino,  on  the  other  hand, 
assert  that  the  emptying  of  the  stomach  after  a  full  meal 
is  not  only  accomplished  within  the  period  of  physiological 
limit,  but  is  actually  accelerated.  They  add  :  '  This  is  often 
observed  immediately  after  the  operation,  and  almost,  or 
almost  always,  in  the  months  that  follow.' 

Ulcus  Pepticum. — Cases  of  peptic  ulcer  in  the  jejunum  after 
gastro-enterostomy  are  recorded  by  Braun,  Halm,  Kausch, 
Korte,  Steinthal,  Hadra,  and  Neumann.  In  four  cases  the 
ulcer  perforated  and  proved  fatal.  All  the  operations  were 
performed  when  hyperchlorhydria  was  marked  and  persistent. 
Under  such  condition,  Neumann  suggests  that  the  operation 
of  jejunostomy  should  be  performed.  The  opening  made  in 
the  bowel  can  be  closed  as  soon  as  the  gastric  juice  has 
returned  to  its  normal  condition  {Dent.  Zcit.  f.  Chir., 
1901). 

Results  of  Gastro-enterostomy. 

Chlumskij  {Beit.  z.  Klin.  Chir.,  1898)  has  collected 
550  cases  of  gastro-enterostomy,  which  show  the  following 
results : 

Between  the  years  1881  and  1885,  35  cases — 12  recoveries, 
23  deaths  =  65-71  per  cent. 

Between  the  years  1886  and  1890,  114  cases — 61  recoveries, 
53  deaths  =  47  per  cent. 

Between  the  years  1891  and  i8g6,  401  cases — 265  recoveries, 
136  deaths  =  33'9i  per  cent. 


OPERATIONS  UPON  THE  STOMACH  279 

The  mortality  for  all  classes  of  case  is  seen  to  be  a 
gradually  diminishing  one.  There  is,  however,  an  obvious 
and  a  striking  difference  between  cases  of  cancer  and  cases 
of  simple  stenosis  or  ulceration.  Haberkant  calculates  a 
mortality  of  43*5  per  cent,  in  malignant,  and  of  25*5  per 
cent,  in  simple  cases;  Chlumskij  4i'6  per  cent,  for  malignant, 
and  2 1 "4  per  cent,  for  simple  cases;  Goffe  (quoted  by  Barker) 
for  English  and  American  cases,  41*5  per  cent,  and  36"3  per 
cent,  respectivel}'. 

In  the  Hunterian  Lectures,  Mayo  Robson  tabulated 
1,978  cases  with  720  deaths,  a  mortality  of  36*4  per  cent. 

The  following  is  a  complete  list  of  all  our  gastro-enteros- 
tomies.  We  have  divided  them  into  simple  and  malignant 
cases,  and  the  simple,  again,  into  those  done  b}-  the  anterior 
and  those  by  the  posterior  method  : 

Posterior  Gastro-enterostomy  for  Simple  Diseases  of 
THE  Stomach. 

Case  i.- — Mr.  J.  S.,  of  Batley,  aged  forty-iive.  Seen  at  in- 
firmary. Two  years'  pain.  Nine  months'  vomiting.  Great 
dilatation.  Thickening  and  puckering  near  pylorus.  Explora- 
tory gastrotomy.  Large  ulcer  on  posterior  wall.  Operation 
June  12,  1900  (posterior  gastro-enterostomy).  Complete  re- 
covery.    Well  1 90 1. 

Case  2. — Mrs.  H.,  aged  twenty-three.  Seen  with  Dr.  Humph- 
ery  of  Armley.  Acute  haematemesis.  Numerous  ulcers.  Opera- 
tion July  6,  1900  (post-gastro-enterostomy  after  gastrotomy). 
Quite  well  1901.     Full  report  under  Haematemesis. 

Case  3. —  Miss  H.,  aged  thirty-two.  Seen  with  Dr.  Angus  of 
Bingley.  Ten  years'  history  of  gastric  ulcer.  Haematemesis 
1892  and  1896.  Great  dilatation.  Pyloric  ulcer  and  stenosis. 
Operation  October  5,  1900  (posterior  gastro-enterostomy).  At 
operation  6  stones  12  pounds.     Now  8  stones  6  pounds. 

Case  4. — Mr.  H.,  aged  fifty-five.  Seen  with  Dr.  Hearder  of 
Ilkley.  Symptoms  of  ulcer  three  years.  Modified  hour-glass 
stomach.  Great  loss  of  flesh.  Dilatation  of  stomach.  Anaemic, 
and,  though  6  feet,  only  weighed  8  stones  6  pounds.  Operation 
October  12,  1900.  Recovery.  At  operation  8  stones  6  pounds. 
Now  9  stones  11  pounds  and  quite  well. 

Case  5. — Mr.  H.,  aged  thirty-five.  Seen  with  Dr.  Mercer  of 
Bradford.     Pancreatic  abscess  due  to  ulcer  of  stomach.     See  full 


28o  SURGERY  OF  THE  STOMACH 

notes  under  Perforation.  Operation  October  i8,  1900.  Recovery. 
Quite  well  April,  1901. 

Case  6. — Miss  R.  B.,  of  Bradford,  aged  thirty-one.  Seen  at 
infirmary.  Six  years'  pain  and  vomiting.  Haematemesis.  Last 
attack  three  weeks  before.  Great  loss  of  fles:h.  \\'eight  6  stones 
II  pounds.  Operation  June  18,  1900.  October  19,  weighs 
7  stones.     Quite  well. 

Case  7. — Mrs.  A.  P.,  of  Cleckheaton,  aged  thirty-eight.  Seen 
at  infirmary.  Five  years'  history.  Tenderness  at  epigastrium. 
Pain  after  food  and  vomiting.  Loss  of  weight  extreme.  Opera- 
tion November  i,  1900.     Good  recovery. 

Case  8. — Miss  D.  B.,  of  Grantham,  aged  twenty-five.  Seen 
at  infirmary.  Extensive  ulceration  and  contraction  of  stomach. 
Hour-glass  distortion.  Active  ulceration  at  constriction.  Opera- 
tion November  15,  1900.  Recovery.  Convalescence  tardy,  and 
had  to  keep  on  milk  for  some  time.  April,  1901,  has  gained 
7  pounds. 

Case  9. — iSIrs.  G.  W.,  of  Birstall,  aged  fifty.  Seen  at  in- 
firmary. Thirty-six  years'  history.  Haematemesis.  No  solid 
food  for  eight  months.  Free  HCI.  8  stones  i^  pounds.  No 
tumour.  \'ery  strong  adhesions  to  anterior  abdominal  wall.  Old 
perforation.  Operation  November  29,  igoo.  Good  recovery. 
Restoration  to  health. 

Case  10. — Mrs.  R.  Seen  with  Dr.  \\'est,  Morley.  Extreme 
dilatation  of  posterior  wall  after  gastroplication  of  anterior.  Peri- 
gastritis (see  notes  at  length  elsewhere).  Severe  pain  after 
food.  Operation  December  5,  1900.  Reco\ery.  Well  April, 
1901. 

Case  ii. — Mr.  J.  H.,  of  Culgaith,  aged  fifty-three.  Seen  at 
infirmary.  Two  years'  history.  Pain  after  food.  Lost  3  stones. 
Free  HCI.  Hour-glass  contraction  3  inches  from  pylorus. 
Operation  December  6,  1900.  Recovery.  Convalescence  re- 
tarded by  vomiting  fortnight  after  operation,  necessitating  milk 
diet  for  a  time.     Solids  taken  freely  later.     Complete  recovery. 

Case  12.— Mr.  W.  H.  M.,  of  Cleckheaton,  aged  fifty-four. 
Seen  at  infirmary.  Six  years'  history  of  ulcer  and  vomiting  at 
intervals.  Lost  2  stones  in  weight.  Tenderness  at  epigastrium. 
Dilatation.  Free  HCI.  Stomach  puckered  and  thickened. 
Strong  adhesions.  Weight  8  stones  11  pounds.  Operation 
December  20,  1900.     Recovery.     Out-patient  January  14. 

Case  13. — Mr.  H.  H.,  of  Northallerton,  aged  forty.  Seen  at 
infirmary.  Twenty-two  years'  history.  Two  years'  symptoms, 
severe.  Slight  haematemesis.  Tenderness.  Dilatation.  9  stones 
10  pounds.  Adhesions.  Scars  of  ulcers  on  anterior  surface. 
Operation  January  3,  1901.      Good  recovery. 


OPERATIONS  UPON  THE  STOMACH  281 

Case  14. — Mrs.  L.,  aged  thirty-eight.  Seen  with  Dr.  Mackenzie 
of  Burnley.  Indigestion  twenty  years.  Pain  constant ;  lately 
i\  hours  after  food.  Pain  easier  on  lying  down  and  on  face.  Lost 
I  stone  II  pounds.  Scars  of  ulcers  on  pylorus  and  anterior  wall. 
Stenosis  of  pylorus.  Glands  in  lesser  omentum.  Operation 
January  8,  1901.     Recovery.     6  stones   11  pounds  at  operation; 

7  stones  9  pounds  two  months  later. 

Case  15. — Mrs.  I.,  aged  thirty-six.  Symptoms  of  gastric  ulcer 
five  years.  Once  perforation  suspected.  Severe  haematemesis 
at  first.  Adhesions  to  anterior  abdominal  wall,  etc.  Operation 
January  21,  1901.     Recovery.     Well  April. 

Case  16. — Miss  D.,  aged  forty-nine.  Seen  with  Dr.  Hindle. 
(See  full  report  under  Hour-glass  Stomach,  p.  173.)  Operation 
January  24,  1901.      Recovery.     8  stones  5  pounds  at  operation; 

8  stones  g  pounds  a  month  later. 

Case  17. — ^Irs.  E.  W'.,  of  Barnsley,  aged  thirty-six.  Seen  at 
infirmary.  Two  years'  pain  after  food.  \'omiting  at  times. 
.Melasna.  9  stones  8  pounds  to  7  stones  4  pounds.  Dilated 
stomach  to  i  inch  below  umbilicus.  Free  HCl  present.  Opera- 
tion January  31,  1901.     Good  recovery.     Well  April,  1901. 

Case  18. — Mrs.  M.  B.,  aged  fifty-six.  Seen  at  infirmary. 
Three  years  ago  gastro-enterostomy  done  for  peripyloritis  from 
^all-stones  (Murphy).  Return  of  symptoms.  Dilated  stomach. 
Operation  February  5,  1901.     Recovery.     ]Much  relieved. 

Case  19. — Miss  S.  H.,  of  Harrogate,  aged  twenty-one.  Seen 
at  infirmary.  Six  years'  digestive  troubles  with  vomiting.  Con- 
tracted and  scarred  stomach.  Tenderness  at  epigastrium.  Free 
HCl.  Weight  6  stones  2  pounds.  Stomach  extensively  ulcer- 
ated and  thickened  and  puckered.  Operation  February  8,  1901. 
Recovery.  February  21  had  got  to  take  solids;  then  vomited 
blood  and  had  great  pain.  Rectal  feeding,  then  milk,  etc.,  given. 
Well  April  and  taking  ordinary  food. 

Case  20. — Mrs.  M.  A.  G.,  aged  forty-four.  Seen  at  infirmary. 
Chronic  ulcer  fourteen  months.  Large  incompetent  stomach. 
Ulcer  on  posterior  wall,  near  pylorus.  Operation  February  11, 
1901.     Recovery.     Quite  well  April  3,  1901. 

Case  21. — -Mrs.  M.  H.,  aged  twenty-two.  Seen  at  infirmary. 
Intractable  ulcer  for  nearly  one  year,  unrelieved  by  treatment. 
Hyperchlorhydria.  Reichmann's  disease.  Operation  February  12, 
1 90 1.     Recovery. 

Case  22. — Mr.  S.,  aged  sixty-four.  Seen  with  Dr.  Thorburn 
■of  Sedbergh.  Two  years'  history  of  pain  and  vomiting — lately 
■coffee-ground  vomit  in  large  quantity.  No  tumour  felt.  At 
■operation  thickening  along  lesser  curvature  and  at  pylorus. 
Glands.      Very  feeble   indeed.       Operation    February    14,    1901. 


282  SURGERY  OF  THE  STOMACH 

Uninterrupted  recovery.  April  4,  1901,  letter  to  say  he  has 
gained  2  stones  since  operation. 

Case  23. — Mrs.  S.  B.,  aged  thirty-one.  Seen  at  infirmary. 
Symptoms  of  chronic  gastric  ulcer  for  some  years.  For  five  to 
six  months  pain  and  vomiting  severe  and  disabling.  Dilated 
stomach.  Three  ulcers  seen.  Operation  February  16,  1901. 
Recovery.     Complete  relief. 

Case  24. — Mrs.  L.  S.,  aged  thirty-one.  Seen  at  infirmary. 
Perigastritis,  the  result  of  gall-stones.  Large  stomach,  with 
characteristic  signs  and  symptoms  of  dilatation.  Operation 
February  19,  1901.     Recovery.     Entirely  relieved. 

Case  25.— Mrs.  E.  W.,  aged  twenty-seven.  Seen  at  infirmary. 
Gastric  ulcer.  Under  treatment  for  nearly  two  years  without 
relief.  Hyperchlorhydria.  Reichmann's  disease.  Operation 
February  19,  1901.     Recovery. 

Case  26. —  Mr.  W.  B.,  aged  sixty.  Seen  at  infirmary.  Ulcer- 
ated stomach  twenty  years  ago.  Under  constant  treatment  for 
two  years  with  pain  and  frequent  vomiting.  Dilated  stomach. 
"Ulcer  I  inch  from  pylorus.  Operation  February  22,  1901. 
Recovery. 

Case  27. —  Mr.  H.  Seen  with  Dr.  Irving  of  Huddersfield. 
Dilatation  of  stomach.  Probably  congenital  stenosis.  Operation 
February  25,  1901.     Recovery. 

Case  28. — Miss  N.  G.,  of  Sheffield,  aged  twenty-seven.  Seen 
at  infirmary.  Pain  and  indigestion  since  she  was  a  girl ; 
vomiting  at  times.  Stomach  dilated  and  tender.  Loss 
of  weight.  Free  HCl.  Weight  7  stones  6  pounds.  Opera- 
tion March  7,  1901.  Recovery.  Soft  solids  allowed  at  month 
end ;  ultimately  good  recovery,  and  can  take  food  without 
pain. 

Case  29. — Miss  B.,  aged  thirty.  Seen  with  Dr.  Empey  of 
Cross  Hills.  Ten  years'  symptoms.  Dilatation  halfway  to 
■pubes.  Weight  5  stones  3  pounds ;  once  7  stones.  Vomiting, 
pain  and  tetany.  Operation  March  8,  1901.  Recovery.  Re- 
turned home  at  end  of  month.  Looks  much  better  and  says 
feels  well. 

■  Case  30.  —  Lady,  aged  fifty-two.  Seen  with  Dr.  Findlater. 
Stomach  symptoms  for  many  years.  Fourteen  years  and  eight 
years  ago  severe  hgematemesis.  Liquid  food  in  small  amounts 
can  only  be  taken.  Very  thin  and  feeble.  Stomach  small  and 
thickened.  Numerous  scars  seen  on  stomach.  Operation 
March  20,  1901.  Recovery.  Letter  on  April  10  to  say  lost  pain 
and  taking  food  well. 

Case  31. — Mr.  F.,  aged  sixty-three.  Seen  with  Dr.  White, 
Essex.       (See    full    report     under     Haematemesis).       Operation 


OPERATIONS  UPON  THE  STOMACH  285 

March  22,  igoi.  Recovery.  Left  fourth  week.  Can  eat  any- 
thing and  feels  well.     Gained  4  pounds  in  fourth  week. 

Case  32. — Miss  G.,  aged  twenty-seven.  Seen  with  Dr.  Dolan, 
Halifax.  Symptoms  of  ulcer  six  years.  Loss  of  weight. 
Anaemic.  Pain  \\  hours  after  food.  Tenderness.  At  operation 
scars  of  ulcers  found.  Operation  March  22,  igoi.  Recovery. 
Returned  home  well  April  17,  igoi. 

Case  33. — Mr.  A.  P.,  aged  thirty-two.  Seen  at  infirmary. 
Duodenal  ulcer.  Melaena.  Vomiting  for  five  years.  Large 
duodenal  ulcer  and  scar  of  gastric  ulcer.  Operation  March  24, 
1 90 1.     Recovery. 

Case  34.- — Mr.  F.  H.,  aged  twenty-two.  Seen  at  infirmary. 
Five  months'  pain  and  vomiting  after  food.  Haematemesis. 
Loss  of  18  pounds  in  weight.  Very  slight  jaundice.  Stomach 
reaches  to  umbilicus.  Free  HCl  in  stomach  contents.  Adhesions 
and  cicatrix  found.  Operation  March  28,  1901.  Uninterrupted 
recovery.     Fish  on  fourteenth  day. 

Case  35. — Mr.  A.  M.,  aged  twenty-three.  Seen  at  infirmary. 
Three  years'  vomiting  at  intervals.  Wasting  17  pounds.  Tetany. 
Has  washed  stomach  out  ten  months.  Stomach  dilated  to  umbi- 
licus. Weight  7  stones  4  pounds.  Free  HCl  in  stomach. 
Scarring  near  pylorus.  Operation  March  28,  1901  (post-gastro- 
enterostomy).     Bone  bobbin.     Recovery. 

Case  36. — Miss  A.  R.,  aged  thirty-nine.  Seen  at  infirmary. 
Indigestion  eight  years.  Pain  after  food.  Nine  months  ago 
pain  in  left  loin  ;  three  months'  pain  2  inches  above  umbilicus. 
Flatulence.  Steady  loss  of  weight.  Loss  of  8  pounds  during 
last  year.  Stomach  dilated  nearly  to  pubes.  Upper  border  lower 
than  normal.  Movable  kidneys,  especially  the  left.  Weight 
7  stones  3  pounds.  Free  HCl  reduced  in  amount.  Shortening 
of  lesser  omentum.  Scar  on  posterior  wall  of  stomach.  Opera- 
tion March  28,  1901  (post-gastro-enterostomy).  Bone  bobbin. 
Died  twelfth  day.  Septic  wound,  leading  to  peritonitis.  No 
leakage  between  stomach  and  bowel.     Kidneys  granular. 

Case  37. — Mr.  C.  R.  R.,  aged  twenty-six.  Seen  at  infirmary. 
Four  years'  indigestion.  Two  months'  severe  pain  in  epigastrium 
after  food.  Retching  and  nausea.  Great  loss  of  weight  and 
strength.  Stomach  when  distended  reached  2  inches  below 
umbilicus.  Free  HCl  found.  Patient  extremely  feeble  and  thin. 
Had  been  under  medical  supervision  for  many  months.  For 
three  months  had  lived  on  liquids  because  of  pain  after  food. 
Weight  6  stones  i  pound.  Operation  March  28,  igoi.  Died 
eleventh  day.  Phthisis,  right  apex.  Pneumonia,  right  base 
(?  due  to  ether).  Wound  healed.  No  peritoneal  condition. 
Union  between  stomach  and  bowel  satisfactory. 


284  SURGERY  OF  THE  STOMACH 

Case  38. — Miss  N.  Seen  with  Dr.  Barrs.  Symptoms  of  ulcer 
for  several  years.  Great  loss  of  flesh  and  debility.  Three  ulcers 
seen  on  anterior  surface  of  stomach  and  one  on  posterior.  Great 
•dilatation.     Operation  April  3,  1901.     Good  recovery. 

Case  39. — Mrs.  J,  W.  T.,  aged  forty-two.  Seen  at  infirmary. 
Four  years'  pain  and  vomiting  after  food.  Loss  of  22  pounds  in 
weight.  Unable  to  work  or  gain  a  living.  Stomach,  when  un- 
distended,  reaches  to  within  i  inch  of  umbilicus.  When  dis- 
tended with  CO.,,  much  below  umbilicus.  Vomiting  frequent. 
Pain  after  food.  Operation  April  4,  1901  (post-gastro-enteros- 
tomy).  Bone  bobbin.  Recovery.  Has  not  vomited  since  opera- 
tion.    Wound  healed  by  first  intention. 

Case  40.- — Miss  A,  R.,  aged  thirty-six.  Seen  at  infirmary. 
Ten  years'  indigestion.  Had  haematemesis  four  years  ago.  Two 
years'  severe  pain  after  food.  Loss  of  6  pounds  in  last  six  months. 
Unable  to  take  solid  food  because  of  pain.  Invalid  for  nine 
months.  Dilated  stomach  reaching  below  umbilicus.  Tender- 
ness at  epigastrium.  Operation  April  4,  1901  (post-gastro- 
■enterostomy).     Bone  bobbin.     Recovery. 

Total :  forty  cases.     Two  deaths. 


Anterior  Gastro-enterostomy  for  Simple  Disease 
OF  the  Stomach. 

Case  i. — Mr.  J.  S.,  aged  fifty-four.  Seen  at  infirmary.  Con- 
traction of  scar  after  pylorectomy.  Operation  September  10, 
1 891.  Senn's  plates.  Death  fourth  day  from  exhaustion.  Post- 
mortem.    No  peritonitis  and  union  good. 

Case  2. — Mrs.  M.  S.,  aged  forty-eight.  Seen  at  the  infirmary. 
Two  years'  history  of  pain  after  food,  etc.  Six  months  tumour. 
Operation  December  21,  1893.  Bone  bobbin.  Good  re- 
covery. 

Case  3. — Mr.  R.  C,  aged  forty-five.  Seen  at  infirmary.  Two 
years'  pain  and  vomiting.  Stricture  of  pylorus.  Loss  of  weight 
2  stones  in  four  months.  Weight  8  stones  i^  pounds.  Opera- 
tion September  12,  1895.  Bone  bobbin.  Recovery.  Well  in 
1897. 

Case  4. — Mrs.  M.  B.,  aged  thirty-three.  Seen  at  infirmary. 
Ten  years'  history.  Dilatation.  Visible  peristalsis.  Pain,  vomit- 
ing ;  vomit  acid.  7  stones  2^  pounds.  Operation  February  4, 
1897.    Bone  bobbin.     Recovery.     March,  7  stones  12^  pounds. 

Case  5. — Mr.  G.  L,  aged  twenty-three.  Seen  at  infirmary. 
Six  years'  pain  and  vomiting ;  four  years  ago  haematemesis. 
Has  lost  16   pounds  in  twelve  months.     Operation  October  21, 


OPERATIONS  UPON  THE  STOMACH  285 

1897.     Bone  bobbin  and  omental  graft.     Recovery.     Out-patient 
March  20. 

Case  6. — Dr.  B.,  aged  thirty-one.  Seen  with  Dr.  Barrs. 
Seventeen  years'  pain  and  dyspepsia  ;  vomiting  sixteen  months. 
Stomach  reaches  pubes.  Visible  peristalsis.  Extensive  tumour 
and  discrete  glands.  Weight  8  stones  6  pounds.  Operation 
May  6,  i8g8.  Bone  bobbin.  Recovery.  August  17,  1898, 
weighs  9  stones  3  pounds.     Well  and  in  active  work  1901. 

Case  7. — Mrs.  W.  Seen  with  Dr.  Salter  of  Scarborough. 
Pyloric  stenosis  and  dilatation  of  the  stomach.  Operation 
September  4,  1898.  Bone  bobbin.  Recovery.  Had  regained 
lost  weight  and  health  1900. 

Case  8. — Mr.  A.,  aged  twenty-eight.  Seen  with  Dr.  Kilner 
Clarke  of  Huddersfield.  Chronic  ulcer.  Pyloric  tumour.  Great 
dilatation  of  stomach.  Pain  two  hours  after  food;  vomiting  of 
coffee-ground  material.  Two  years'  history,  and  loss  of  weight 
of  3  stones  6  pounds.  Operation  August  4,  1899.  Bone  bobbin. 
Recovery.  September  20,  weight  10  stones  13  pounds.  \\  ell 
1 90 1. 

Case  9. — Mr,  R.  K.,  aged  thirty-seven.  Seen  at  infirmary. 
Several  years'  pain  after  food,  etc. ;  three  months'  severe  pain  and 
vomiting.  In  three  months  lost  21  pounds.  Stomach  2  inches 
below  umbilicus.  Free  HCl.  Operation  September  28,  1899. 
Bone  bobbin.  Adhesions  around  pylorus  thickened  and  stenosed. 
Death  fourth  day. 

Case  id. — Mr.  C.  W.  C,  aged  thirty-four.  Seen  at  infirmary. 
Tumour  of  pylorus.  Stomach  3  inches  below  umbilicus.  One 
stone  lost  in  twelve  months.  Weight  7  stones  8  pounds.  Opera- 
tion November  9,  1899.  Murphy  button.  Recovery.  Out- 
patient.    Weight  8  stones  8  pounds. 

Case  ii. — Mr.  T.  S.,  aged  twenty-two.  Seen  with  Dr.  Churton 
at  infirmary.  Severe  haematem.esis  ;  lost  2|- stones.  Operation 
for  haematemesis  from  duodenal  ulcer.  Operation  December  i, 
1899.  Murphy  button.  Death.  Leakage  on  ninth  day  -when 
button  separating.  Post-mortem :  Perforated  vessel  found  in 
duodenum,  securely  blocked  by  organizing  clot.  (See  Heema- 
temesis.) 

Case  12. — Mr.  C,  aged  thirty-eight.  Seen  with  Dr.  Peter 
MacGregor  of  Huddersfield.  Pyloric  ulcer  and  haematemesis. 
Operation  January  4,  1900,  Recovery.  Well  April,  1901.  (See 
Haematemesis.) 

Case  13. — Mrs.  E.  B.,  aged  forty-one.  Seen  at  infirmary. 
Gastric  ulcer  when  sixteen  ;  since  then  chronic  dyspepsia,  gradu- 
ally getting  worse.     Four  months'  continuous  medical  treatment 


286  SURGERY  OF  THE  STOMACH 

produced  no  improvement.  Operation  January,  1900.  Laplace's 
forceps.     Recovery.     Complete  restoration  to  health. 

Case  14. — Mr.  A.  B.,  aged  fifty-five.  Seen  at  infirmary. 
Dyspepsia  for  ten  or  twelve  years,  culminating  five  years  ago  in 
an  '  attack '  of  pain  and  continuous  vomiting,  lasting  two  weeks. 
Stomach  descends  behind  pubes.  Operation  January,  igoo. 
Laplace's  forceps.     Recovery.     Return  of  symptoms  ;  see  later. 

Case  15. — Mr.  F.  S.,  aged  thirty-five.  Seen  at  infirmary. 
Gastric  ulcer  two  years  ago,  now  hyperchlorhydria  and  dilatation 
of  stomach.  At  first  great  improvement  under  medical  treatment, 
but  progressive  loss  of  health  for  many  months  now.  Reichmann's 
disease.  Operation  February,  1900.  Laplace's  forceps.  Re- 
covery.    Quite  well  up  to  date. 

Case  16. — Mr.  A.  B.,  aged  fifty-five.  Seen  at  infirmary. 
Return  of  symptoms.  At  second  operation  the  anastomosis 
found  closed  entirely.  Operation  March,  1900.  Murphy  button. 
Recovery.     Complete  relief  April,  1901. 

Case  17. — Miss  L,  aged  thirty-two.  Seen  with  Dr.  Mackenzie 
of  Bradford.  Fifteen  years'  symptoms  of  ulcer.  For  six  years 
lived  on  liquid  food;  lately  bedridden.  Feeble  and  emaciated. 
Stomach  extensively  ulcerated  and  scarred.  Extra  scarring 
2  inches  from  pylorus.  Operation  April  27,  igoo.  Death  twelfth 
day  from  perforation  of  ulcer,  which  occurred  at  12,30  a.m.,  and 
she  died  at  4.30  from  shock.     Very  well  on  morning  of  accident. 

Case  18. — Mr.  F.  H.,  aged  thirty-two.  Seen  at  infirmary. 
Symptoms  for  ten  months.  Very  dilated  stomach  ;  vomits  every 
three  or  four  days.  Operation  June,  igoo.  Suture.  Recovery. 
Can  eat  anything,  and  has  regained  lost  weight. 

Case  19. — Mrs.  S.  H.,  aged  forty-nine.  Seen  at  infirmary. 
Symptoms  nine  months ;  more  severe  for  five  months.  Pain 
for  two  hours  after  food,  and  continuing  until  vomiting  is  induced. 
No  solid  food  for  two  and  a  half  months.  Dilated  stomach. 
Operation  August,  1900.  Suture.  Recovery.  Complete  relief 
April,  1 90 1. 

Total :  nineteen  cases.     Fifteen  recoveries.     Four  deaths. 

Gastro-enterostomy  for  Cancer. 

Case  i.— Miss  E.  G.,  aged  twenty-one.  Seen  at  infirmary. 
Three  months' symptoms.  Pyloric  tumour.  Dilatation.  Opera- 
tion May  I,  1890  (anterior).  Senn's  plates.  Recovery.  Lived 
three  or  four  months. 

Case  2. — Mr.  J.  S.,  aged  fifty-three.  Seen  at  infirmary.  Five 
months'  symptoms.  Tumour  of  pylorus.  Operation  September  8, 
i8gi  (anterior).     Senn's  plates.     Death  October  24. 

Case  3. — Mr.   J.   W.,   aged   thirty-eight.     Seen  at  infirmary. 


OPERATIONS  UPON  THE  STOMACH  287 

Twelve  months'  symptoms  ;  five  months'  tumour.  Fixed  tumour 
and  nodules  in  skin.  Dilatation  of  stomach.  Operation  June  8, 
1892  (anterior).  Bone  bobbin.  Death  June  23.  Exhaustion 
and  vomiting.     Autopsy.     Union  of  new  opening  good. 

Case  4. — Mr.  J.  P.,  aged  forty-three.  Seen  at  infirmary. 
Seven  months'  symptoms.  Tumour.  Dilatation.  Large  growth 
of  pylorus  and  lesser  curvature.  Lost  2  stones.  Operation 
.March  10,  1894  (anterior).  Bone  bobbin.  Death  March  21 
from  exhaustion. 

Case  5. — Mr.  S.  S.,  aged  forty-four.  Seen  at  infirmary. 
.Three  months'  symptoms.  Tumour.  Loss  of  3  stones  8  pounds 
in  that  time.  Operation  November  20,  1895  (gastro-duodenos- 
tomy).     Bone  bobbin.     Death  November  21. 

Case  6. — Mrs.  B.,  aged  sixty-five.  Seen  with  Dr.  Dobson. 
Cancer  of  pylorus.  Tumour  four  months.  Extremely  feeble  ; 
constant  vomiting.  Dilatation  of  stomach.  Operation  Novem- 
ber 25,  1895  (anterior).     Death  from  shock. 

Case  7.- — Mr.  C,  aged  fifty-nine.  Seen  with  Dr.  Lockie  of 
Carlisle  and  Dr.  Gordon  Black  of  Harrogate.  Cancer  of  pylorus 
and  stomach,  rather  extensive.  Operation  July  6,  1896  (anterior). 
Recovery.     Lived  four  months  in  comfort. 

Case  8. — Mr.  G.,  aged  fifty-two.  Seen  with  Dr.  Woodcock  of 
Beeston.  Thirteen  years'  history  of  ulcer  ;  tumour  recent.  Cancer 
of  pylorus  and  dilatation.  Operation  August  5,  i8g6  (anterior). 
Died.     Extravasation  sixth  day. 

Case  9. — Mr.  C.  M.,  aged  forty-nine.  Seen  at  infirmary. 
Dilated  stomach.  Vomiting.  Loss  of  weight.  Cancer  of 
pylorus.  Operation  November  19,  1896  (anterior).  Recovered. 
Case  10. — Mrs.  M.  W.,  aged  thirty-two.  Seen  at  infirmary. 
Symptoms  five  months.  Vomiting,  pain,  dilated  stomach,  and 
pyloric  tumour.  Growth  ;  secondary  deposits  in  liver.  Con- 
tinuous uncontrollable  vomiting  for  three  weeks.  Operation 
July  3,  1896  (anterior).  Murphy  button.  Recovered.  Lived 
fifteen  weeks. 

Case  ii. — Mr.  J.  C,  aged  forty-six.  Seen  at  infirmary. 
Swelling  at  pylorus,  dilated  stomach,  great  wasting.  Large 
malignant  nodule  in  liver.  Operation  May  14,  1898  (anterior). 
Murphy  button.     Recovered.     Died  December  30,  1898. 

Case  12. — Mr.  F.  W.,  aged  fifty-one.  Seen  at  infirmary. 
Malignant  tumour  at  pylorus  ;  vomiting,  emaciation.  Operation 
May  20,  1898.     Murphy  button.     Recovery.     Lost  sight  of. 

Case  13. — Mr.  A.  C,  aged  forty.  Seen  at  infirmary.  Four 
years'  symptoms  of  ulcer,  indigestion,  and  vomiting.  Lost 
2  stones.  Tumour.  Operation  May  26,  1898.  Murphy  button. 
Recovery.     Returned  to  work.     Died  August  29,  1899. 


288  SUKGERY  OF  THE  STOMACH 

Case  14. — Mrs.  E.  W.,  aged  twenty-nine.  Seen  at  infirmary. 
Large  tumour  at  pylorus ;  great  emaciation.  Vomiting  incessant. 
Operation  July  6,  1898  (posterior).  Murphy  button.  Recovery, 
Lived  fifteen  weeks  without  any  vomiting ;  very  greatly  relieved. 
Case  15. — Mrs.  A.  K.,  aged  forty.  Seen  at  infirmary.  Tumour 
equal  to  walnut  at  pylorus  ;  vomiting,  wasting,  etc.  Secondary 
nodules  and  extensive  glands.  Operation  February  20,  1899 
(posterior).  Murphy  button.  Died  eighth  day.  Deposit  in  lungs. 
Acute  oedema  of  lungs. 

Case  16. — Mr.  M.  C,  aged  forty-seven.  Seen  at  infirmary. 
Gastric  trouble  for  two  or  three  years.  Vomiting  and  pain. 
Lost  14  pounds  in  last  eleven  weeks.  No  tumour  felt.  At 
operation  extensive  malignant  disease.  Operation  August  1, 
1899  (anterior).     Murphy  button.     Died  fifth  day.     Shock. 

Case  17. — Mrs.  S.,  aged  thirty-seven.  Seen  with  Dr.  Dim- 
mock  of  Harrogate.  Cancer  of  body  of  stomach  and  pylorus. 
Dilatation  of  stomach.  Operation  December  21,  1899.  Re- 
covery. Good  recovery,  and  was  so  well  that  gastrectomy  was 
advised  ;  but  cancer  of  uterus  supervened  and  prevented  further 
operation.     Lived  nine  months. 

Case  18. — Mr.  J.  S.,  aged  forty-three.  Seen  at  infirmary. 
Three  and  a  half  years'  history  of  pain  and  vomiting ;  lost 
2  stones  in  weight  in  two  years.  Operation  January  19,  1900 
(anterior).  Bobbin.  Died  next  day,  congestion  of  lungs.  Autopsy: 
Pylorus  adherent  to  mass  of  growth  in  head  of  pancreas ;  calculi 
in  gall-bladder. 

Case  19. — Mrs.  J-  H.,  aged  fifty-two.  Seen  at  infirmary.  Loss 
of  weight,  vomiting,  dilated  stomach.  Malignant  disease  of 
pylorus.  Operation  June  6,  1900  (anterior).  Suture.  Re- 
covery.    Still  living. 

Case  20. — Mrs.  S.  T.,  aged  thirty-six.  Seen  at  infirmary. 
Nine  months'  constant  vomiting ;  extremely  feeble.  Annular 
cancer  3  inches  from  pylorus  (hour-glass).  Operation  September 
23,  1900  (anterior).  Bone  bobbin.  Died  from  exhaustion  on 
fifteenth  day.     Life  prolonged  by  operation  and  greater  comfort. 

Case  21. — Mr.  H.  B.,  aged  sixty-three.  Seen  at  infirmary. 
Twelve  months'  tumour.  See  full  notes  under  Gastrectomy. 
Operation  November  15,  1900  (posterior).  Recovery.  Subse- 
quent gastrectomy. 

Case  22. — Mrs.  M.  S.,  aged  fifty-four.  Seen  at  infirmary. 
Twelve  months'  history.  Much  vomiting.  Tumour  in  epi- 
gastrium. Cancer  along  lesser  curvature.  Too  weak  for  gastrec- 
tomy. Operation  January  17,  1901  (posterior).  Recovery, 
Made  an  out-patient ;  much  relieved. 

Case    23. — Mrs.    A.    C,   aged    fifty-two.     Seen    at   infirmary. 


OPERATIONS  UPON  THE  STOMACH  289 

Stomach  trouble  for  several  years.  Emaciation,  vomiting,  etc. 
Malign mt  disease  at  pylorus  ;  adhesions  to  pancreas.  Posterior. 
Suture.     Recovery.     Still  living. 

Total :  twenty-three.     Recovered  thirteen.     Died  ten. 

Pylorectomy,  or  Partial  Grastrectomy. 

Merrem  in  18 10  showed  by  experiment  upon  a  dog  the  possi- 
bility of  successful  removal  of  the  pylorus.  In  1876  Gussen- 
bauer  and  Winiwarter,  and  later  Czerny  and  Kaiser,  per- 
formed many  successful  operations  upon  dogs,  and  suggested 
the  feasibility  of  the  procedure  in  the  human.  On  April  g, 
1879,  Pean  performed  the  first  pylorectomy  in  man  ;  in  1880 
Rydygier  operated — both  unsuccessfull3\  On  February  28, 
1881,  Billroth  performed  the  first  operation,  followed  by 
recovery. 

The  abdomen  is  opened  in  the  manner  previously  described. 
The  area  to  be  operated  upon  is  surrounded  with  compresses 
or  sponges.  The  vessel  in  the  small  omentum  is  ligatured  in 
two  places  and  divided.  The  fingers  are  then  passed  from 
above  behind  the  pylorus,  and  made  to  define  the  vessels  of 
the  great  omentum,  which  are  similarly  ligatured.  Any 
adhesions  are  gently  separated.  Those  between  the  pylorus 
and  the  pancreas  are  the  most  serious  and  the  most  difficult 
to  deal  with.  The  majority  of  surgeons  consider  that  dense 
adhesions  here  forbid  any  attempt  at  extirpation,  but  it  is 
interesting  to  note  that  in  two  cases  recorded  by  Obalinski 
and  M.  Richardson,  in  which  the  adhesions  were  so  tough  as 
to  prevent  their  stripping,  a  portion  of  the  head  of  the 
pancreas  was  successfully  removed.  A  similar  removal  in  a 
case  of  cancer  is  recorded  by  Christy  Wilson.  If  the 
pancreas  be  denuded,  it  should  be  covered  by  peritoneum 
borrowed  from  the  lesser  sac.  Lymphatic  glands  are  now 
sought  for  and  removed.  x\s  shown  by  Mikulicz,  Kader  and 
Cuneo,  the  most  numerous  and  the  most  important  lie  along 
the  lesser  curvature.  All  these,  as  they  lie  along  the  coronary 
artery,  must  be  removed.  In  excising  glands  from  the  great 
omentum  there  is  great  danger  of  wounding  the  middle  colic 
artery,  and  thereby  causing  gangrene  of  the  transverse  colon. 
The  glands  along  the  greater  curvature  are  most  numerous 

19 


290 


SURGERY  OF  THE  STOMACH 


near  the  pylorus.  The  stomach  and  duodenum  are  then 
clamped  and  divided.  (The  most  serviceable  clamps  are 
Doyen's  hysterectomy  clamps  shielded  with  indiarubber 
tubing,  or  Kocher's  clamps,  specially  devised  for  this  purpose.) 
Examination  of  a  large  number  of  specimens  shows  clearly 
that  malignant  disease  of  the  stomach  rarely  infiltrates  far 
into  the  duodenum,  but  does  extend  readily  and  rapidly 
towards  the  cardiac  end  of  the  stomach.  In  dividing  the 
duodenum,  then,  it  will  suffice  to  remove  2  centimetres  of 
apparently  healthy  tissue  beyond  the  growth.  In  cutting 
across  the  stomach  the  incisions  should  be  ih  to  2  inches 


Fig.  63.  — Partial  Gastrectomy. 


wide  of  the  disease  at  least.  Pathological  observations  show 
that  implication  of  the  stomach  along  the  lesser  curvature 
and  of  the  glands  there  is  early  and  rapid,  and  the  record  of 
cases  operated  upon  in  which  the  disease  recurs  clearly 
proves  the  marked  frequency  of  local  return,  rather  than 
metastasis,  as  the  cause  of  death.  It  is  therefore  probable 
that  permanently  successful  operations  will  depend  upon  a 
very  wide  local  removal,  especially  of  the  upper  border  of  the 
stomach.  We  are  strongly  inclined  to  believe  that,  even  in 
the  earliest  examples  of  pyloric  growth,  a  removal  of  at  least 
half,  possibly  more,  of  the  stomach  is  necessary. 

Union  of  the  stomach  and  duodenum  may  be  carried  out 
in  one  of  three  ways  : 


OPERATIONS  UPON  THE  STOMACH  291 

1.  Immediate  suture  of  the  cut  ends  (Billroth's  first 
method). 

2.  Suture  of  the  stomach  opening  ;  implantation  of  the 
duodenal  cut  end  to  the  posterior  surface  of  the  stomach 
(Kocher). 

3.  Closure  of  both  openings,  and  performance  of  a  gastro- 
jejunostomy (Billroth's  'second  method  "). 

I.  Immediate  union  of  cut  ends,  advocated  by  Mikulicz  and 
Kronlein,  is  best  carried  out  by  means  of  Robson's  bone 
bobbin.  The  inequality  in  the  size  of  the  two  openings  is 
overcome  by  partial  suture  of  the  stomach  incision,  or  by  the 
making  of  a  horizontal  slit  in  the  duodenal  end.  It  is  of  the 
first  importance  that  the  new  opening  should  be  large,  as 
several  cases  are  recorded  in  which  subsequent  contraction 
of  the  orifice  demanded  a  further  operation.  The  method  of 
suture  is  similar  to  that  already  described  in  gastro-enter- 
ostomy.  The  bobbin  is  of  the  greatest  possible  advantage 
here.  A  very  large  proportion  of  deaths  in  cases  of  simple 
suture  have  been  due  to  leakage  at  what  has  been  termed 
'the  fatal  suture  angle  of  Billroth.'  This  danger  is  wholly 
avoided  by  the  use  of  the  bobbin. 

If  simple  suture  is  the  method  chosen,  it  may  be  carried 
out  by  the  plan  advocated  by  Rutherford  Morison. 

After  removal  of  the  pylorus,  the  stomach  opening  is 
larger  than  the  duodenal.  An  incision  over  i  inch  in  length 
is  made  down  the  centre  of  the  anterior  wall  of  the  duo- 
denum. By  spreading  this  longitudinal  cut  transversely  the 
duodenal  opening  is  so  widened  as  to  correspond  in  size  with 
the  stomach  opening.  The  two  viscera  are  now  united.  The 
posterior  wall  of  the  opening  which  is  to  serve  as  the  artificial 
pylorus  is  first  made.  A  long  catgut  suture  threaded  in 
an  ordinary  needle  is  introduced  through  all  the  coats  in  the 
position  of  one  of  the  outer  three  temporary  sutures  used  to 
show  the  exact  relation  of  parts.  This  suture  is  securely 
tied,  has  its  short  end  clamped  in  haemostatic  forceps,  and 
takes  the  place  of  the  temporary  suture.  The  longer 
threaded  end  is  used  as  a  continuous  stitch  through  all  the 
coats  of  the  stomach  and  duodenum,  and  brings  ■  their 
apposed   surfaces  into  firm   apposition.      The   middle    tem- 

ig — 2 


292 


SURGERY  OF  THE  STOMACH 


porary  suture  being  reached,  it  is  withdrawn,  and  the  con- 
tinuous stitch  travels  on  to  the  further  temporar}-  one,  which 
it  replaces. 

The  posterior  wall  is  now  formed  by  a  continuous  catgut 
suture  passed  from  within  outwards  through  all  the  coats, 
and  bringing  the  peritoneal  surfaces  of  stomach  and  duo- 
denum into  firm  apposition.  The  anterior  wall  is  next  made 
in  a  similar  way  by  a  continuous  catgut  stitch  through  all 
the  coats,  but  here  the  suture  cannot  be  passed  from  within, 
and  of  course  does  not  bring  the  peritoneal  coats  into  appo- 


FiG.  64. — Partial  Gastrectomy.     (Kocher's  Operation.) 


sition  as  it  does  posteriorly.  The  object  of  this  continuous 
catgut  stitch  is  to  secure  a  temporary  watertight  junction 
between  the  two  viscera.  To  secure  broad  permanent  ad- 
hesion between  stomach  and  duodenum,  a  ring  of  fine  silk 
interrupted  sutures  through  peritoneal  and  muscular  coats 
only  is  placed  all  round  the  temporary  junction  effected,  and 
completely  buries  it. 

2.  Kocher's  Method. — Suture  of  the  stomach  incision  ;  im- 
plantation of  the  cut  end  of  the  duodenum  into  the  posterior 
wall  of  the  stomach.     The  union  may  be  effected  by  a  simple 


OPERATIONS  UPON  THE  STOMACH  293 

suture,  bobbin  or  button.  The  suture  adopted  by  Kocher  is 
most  satisfactory.  Kocher  has  recorded  fifty-seven  cases 
operated  upon  by  this  method,  with  five  deaths.  Although 
the  Murphy  button  has  been  frequently  advocated  and  em- 
ployed, we  feel  strongly  that  by  its  use  there  is  no  saving  of 
time  worth  the  mentioning,  and  the  risks  are  decidedly  grave. 

The  duodenal  cut  end  may  be  implanted  into  the  anterior 
wall  of  the  stomach.  Czerny  has  used  both  the  anterior  and 
the  posterior  methods,  with  and  without  the  Murphy  button, 
but  does  not  express  any  preference  for  one  over  the  others. 

Continuous  sutures  (catgut  for  the  mucous  membrane  and 
silk  or  Pagenstecher  thread  for  the  serous  surfaces)  with  one 
or  more  interruptions  are  employed,  as  in  gastro-enterostomy. 

The  details  of  the  operation  are  as  follows  :  An  incision 
4  or  5  inches  in  length  is  made  in  the  middle  line,  more  or 
less  above  the  umbilicus,  according  to  the  position  of  the 
pylorus.  After  opening  the  abdomen,  the  tumour  is  ex- 
amined carefully  to  determine  the  limits  of  its  infiltration. 
Small  openings  are  made  in  the  greater  and  lesser  omenta 
wide  of  the  growth,  to  enable  the  clamps  to  be  introduced. 
The  omenta  are  then  ligatured  ;  if  any  vessels  are  torn,  they 
are  at  once  secured.  When  the  tumour  is  thus  isolated  it  is 
everywhere  surrounded  with  sterile  compresses.  The  stomach 
is  then  clamped  with  two  Kocher's  clamps,  one  above,  the 
other  below.  The  duodenum  is  closed  with  one  clamp  close 
to  the  growth,  and  a  second  at  a  distance  of  i  inch,  and  the 
gut  is  divided  between  them.  The  cut  surface  is  cleansed 
by  mopping  with  i  in  1,000  sublimate  solution,  and  now, 
and  throughout  the  operation,  care  is  taken  to  avoid  soiling 
by  the  secretions  of  the  stomach  or  intestine.  The  proximal 
end  of  the  duodenum  is  wrapped  in  sterile  gauze  and  drawn 
out  of  the  wound.  An  assistant  now  grasps  the  stomach 
from  above  and  below  between  the  thumb  and  the  index- 
finger,  and  the  stomach  is  divided  between  his  fingers  and 
the  clamps.  The  cut  end  is  dried,  and  any  secretion  which 
escapes  is  carefully  mopped  up.  The  bleeding  vessels  are 
ligatured.  A  continuous  suture  now  closes  the  stomach 
incision,  and  includes  all  the  coats.  A  second  continuous 
Lembert  suture  is  applied,  including  only  the  peritoneum. 


294  SURGERY  OF  THE  STOMACH 

The  assistant  now  seizes  the  stomach,  and  by  pressure  with 
the  thumbs  makes  the  posterior  surface  present  to  the  front. 
The  duodenal  cut  end  is  then  apphed  to  the  posterior  surface 
of  the  stomach,  and  a  continuous  silk  suture  unites  its  serous 
coat  along  the  whole  length  of  the  posterior  half  to  the  pre- 
senting surface  of  the  stomach.  The  duodenal  clamp  is  now 
removed.  The  stomach  is  incised  in  front  of  the  continuous 
suture  along  a  distance  equal  to  the  breadth  of  the  duodenum. 
After  bleeding  is  arrested,  a  continuous  suture  unites  the  cut 
margins  of  the  stomach  and  duodenum  and  includes  all  the 
coats,  or  one  suture  unites  the  muscular  and  another  the 
mucous  surface.  The  anterior  borders  of  the  openings  are 
now  united  in  the  same  manner  as  the  posterior.  The  parts 
are  cleansed  and  replaced  and  the  compresses  removed. 
Kocher  lays  stress  upon  three  points  :  (i)  Rigorous  asepsis ; 

(2)  the    employment    of    continuous    sutures    throughout ; 

(3)  the  use  of  good  clamps.  He  advises  the  use  of  the 
Murphy  button  when  there  is  any  tension  owing  to  an 
inability  to  drag  the  duodenum  forward.  There  is  rarely 
any  difficulty  in  securing  easy  apposition  of  the  duodenum 
and  stomach,  for  the  latter  has  a  remarkably  free  range  of 
movement,  and  can  be  very  easily  pulled  across  to  the 
duodenum.  Kocher  himself  has  removed  the  stomach  to 
within  two  fingers'  breadth  of  the  cardia,  and  yet  secured  an 
apposition  free  from  strain.  An  extension  towards  the  duo- 
denum entailing  a  free  removal  would  furnish  the  chief 
difficulty  to  this  procedure. 

3.  Closure  of  both  Cut  Ends — Performance  of  Gastro-enter- 
ostomy. — After  removing  the  growth,  the  cut  ends  of  the 
stomach  and  duodenum  are  completely  closed  by  continuous 
sutures,  of  catgut  for  the  mucous  membrane  or  all  the  coats, 
and  of  silk  for  the  serous  surface.  An  anastomosis  is  then 
made  between  the  stomach  and  the  jejunum  in  one  of  the 
methods  already  described,  the  posterior  method  being  that 
most  commonly  employed.  The  order  of  the  operations  may 
be  reversed,  as  advised  by  Tupolske  and  Czerny,  the  gastro- 
enterostomy being  first  performed,  and,  after  the  lapse  of  two 
weeks  or  thereabouts,  the  pylorectomy.  This  has  the  advan- 
tage of  lessening  the  demand  made  upon  the  patient's  powers. 


OPERATIONS  UPON  THE  STOMACH  295 

and  of  enabling  some  strength  to  be  gained  by  careful  dieting 
in  the  interval.     The  following  is  an  example  : 

Hour-glass  Stomach  caused  by  Cylinder  of  Cancer  in  the 
Centre.  Gastro-enterostomy  with  Subsequent  Partial 
Gastrectomy  ;  Recovery. 

Mr.  B.,  aged  sixty-two,  was  sent  to  one  of  us — Mayo  Robson — 
by  Dr.  James  Gardner,  of  Burnley,  Lancashire,  suffering  from  a 
movable  tumour,  thought  to  be  cancer  of  the  stomach,  which 
had  been  noticed  for  a  month,  but  which  had  been  preceded  by 
stomach  symptoms,  chiefly  pain  after  food  and  slight  vomiting, 
for  quite  a  year.  There  had  latterly  been  some  slight  coffee- 
ground  vomit,  but  no  large  amount  of  blood  had  been  vomited  at 
any  time.  The  tumour  was  not  tender,  and  could  be  pushed  up 
under  the  left,  and  moved  over  to  the  right,  costal  margin.  A 
stomach  splash  was  well  marked  on  the  left  of  the  tumour,  and 
on  distending  the  stomach  with  CO^  the  lump  was  pushed  over 
to  the  right.  The  vomit  was  acid  from  the  presence  of  lactic 
acid,  but  no  free  HCl  could  be  found. 

Pylorectomy  was  advised,  and  the  patient  was  admitted  to  the 
infirmary,  being  then  in  an  extremely  weak  condition. 

November  15,  1900. — On  opening  the  abdomen  a  mass  of  growth 
was  found  in  the  centre  of  the  stomach,  forming  a  ring  of  cancer, 
and  leaving  a  cavity  on  its  proximahand  distal  sides,  the  cardiac 
cavity  forming  the  dilated  stomach  where  the  splash  on  succussion 
was  felt.  Dr.  Seaton,  who  was  giving  the  anaesthetic,  advised 
that  the  patient  was  too  feeble  to  bear  a  prolonged  operation,  and 
a  colleague  also  confirmed  the  fact  that  the  pulse  could  be  barely 
felt  at  the  wrist.  A  posterior  gastro-enterostomy  was  therefore 
performed,  a  bone  bobbin  being  employed. 

He  soon  rallied  and  made  a  good  recovery,  gaining  flesh  and 
weight,  and  expressing  himself  as  very  well. 

December  20. — The  radical  operation  of  removing  the  growth  by 
partial  gastrectomy  was  performed,  about  half  the  stomach  being 
removed  in  order  to  leave  a  wide  margin  of  healthy  tissue  between 
the  growth  and  the  wound. 

Union  was  effected  by  suturing  the  cardiac  and  pyloric  incision 
together  over. a  bone  bobbin,  catgut  being  used  for  the  mucous 
and  celluloid  thread  for  the  serous  sutures,  the  whole  operation 
being  completed  within  the  hour.  No  glands  were  felt  beyond 
the  resected  area.  Recovery  was  uninterrupted,  and  he  returned 
home  within  the  month,  eating  and  enjoying  food,  and  having 
gained  considerably  in  weight. 

April,  1 901. — He  continues  well  and  active,  and  has  been  able  to 
resume  his  work. 


296  SURGERY  OF  THE  STOMACH 

Partial  Gastrectomy  for  Cancer  of  the  Body  of  the  Stomach. 

The  ideal  operation  for  pyloric  growth  involves  the 
removal  of  so  much  of  the  stomach  wall  that  it  may  be 
properly  called  partial  gastrectomy.  There  are,  however, 
cases  of  mural  cancer  in  which  local  excision  is  necessary. 
For  example,  an  hour-glass  contraction  of  the  stomach  may 
be  caused  by  a  thick  ring  of  growth,  like  a  napkin-ring,  in 
or  near  the  middle  of  the  stomach.  In  such  a  case  the 
growth  may  be  removed,  and  the  cut  edges  of  the  stomach, 
united. 

The  vessels  in  the  small  and  large  omentum  are  ligatured 
and  divided.  The  stomach  being  clamped  on  each  side  by 
a  Doyen's  or  Kocher's  clamp,  the  growth  and  a  wide  area  of 
seeming  healthy  wall  around  it  are  removed.  The  minimum 
distance  between  the  line  of  section  and  the  margin  of  the 
growth  must  be  3  centimetres.  ^Mikulicz  la3's  emphasis, 
upon  the  fact  that  the  frequency  of  local  recurrence  shows 
that  too  little  of  the  stomach  is  generally  removed.  The 
lymphatic  glands  along  the  whole  length  of  the  lesser 
curvature  are  removed  with  or  without  the  stomach  wall 
along  which  they  lie.  If  any  are  found  in  the  great  omentum 
or  along  the  greater  curvature,  they  also  must  be  removed. 
Union  of  the  divided  ends  ma}^  be  effected  by  the  simple 
continuous  suture,  as  in  gastro-enterostomy,  or  by  the  largest 
bone  bobbin,  preferably  the  latter,  as  in  the  following  cases  : 

Canxer  ;   Hour-glass  Stomach.     Partial    Gastrectomy  ; 
Recovery. 

Mrs.  J.  was  sent  to  one  of  us  (Mayo  Robson)  by  Dr.  Forster 
of  Dalton  in  Furness,  January  24,  1901,  with  a  movable  tumour 
in  the  epigastrium  that  had  been  noticed  three  weeks  previously. 
There  had  been  no  vomiting,  although  indigestion,  pain  an  hour 
after  food,  and  loss  of  flesh  and  strength,  had  been  noticed  since 
August,  1899. 

She  weighed  7  stones,  having  weighed  8  stones  or  more 
previous  to  her  illness.  The  tumour  appeared  to  be  the  size  of 
a  tennis  ball,  was  free  from  tenderness,  and  could  be  made  to 
move  across  the  abdomen  from  one  side  of  the  umbilicus  to  the 
other. 

On  distending  the  stomach  with  CO.,,  it  reached  nearly  to  the 


OPERATIONS  UPON  THE  STOMACH  297 

pubes  on  the  left  side,  but  very  little  distension  was  noticed  on 
the  right,  beyond  the  tumour.  She  was  admitted  to  the  infirmary, 
and  on  January  31,  on  exposing  the  stomach,  a  tumour  was  found 
involving  the  whole  circumference  a  short  distance  from  the 
pyloric  end,  so  that  between  the  pylorus  and  the  tumour  a  small 
second  stomach  cavity  existed,  the  dilatation  being  formed  entirely 
by  the  cardiac  complement.  The  tumour  was  completely  excised, 
and  the  distal  and  proximal  portions  united  over  a  bone  bobbin. 
Glands  were  removed  from  the  lesser  and  greater  omentum. 
Ilecovery  was  uninterrupted,  and  the  patient  left  the  hospital 
before  the  month  end,  having  regained  the  weight  lost  during  the 
week  after  operation,  and  having  added  ^  pound  over.  The 
tumour  proved  to  be  cancer. 

Partial    Gastrectomy,  Cholecystectomy,  and  Partl\l 
Hepatectomy  for  Cancer  ;   Recovery. 

-  Mrs.  S.,  aged  fifty-four,  was  sent  to  one  of  us  (Mayo  Robsonj 
\>y  Dr.  Fry  of  Haworth,  on  July  28,  1900.  The  previous  history 
-was  rather  indefinite,  as  the  patient  did  not  think  it  necessary  to 
seek  medical  advice  before  the  previous  April,  She  said  that 
:she  had  been  in  excellent  health  until  November,  1898,  when 
she  began  to  suffer  for  a  month  or  six  weeks  from  spasmodic 
pains  over  the  gall-bladder  region,  but  she  was  never  jaundiced 
after  the  attacks.  She  also  had  pain  at  the  epigastrium  like 
indigestion.  When  Dr.  Fry  saw  her  she  was  suffering  from  a 
■severe  attack  of  pain  in  the  right  hypochondrium  with  vomiting, 
and  was  in  a  state  of  general  collapse.  Her  general  condition  was 
then  unsatisfactory,  as  she  had  lost  considerably  in  weight,  and 
was  evidently  in  failing  health,  there  being  some  slight  swelling 
of  the  legs  and  general  distension  of  the  abdomen.  The  skin  was 
sallow,  with  a  slight  tinge  of  jaundice  ;  the  liver  was  found  to  be 
■enlarged,  and  the  gall-bladder  could  be  felt  as  a  hard  mass,  well 
defined,  about  2  inches  wide  and  3  inches  long.  It  was  tender 
-on  pressure,  and  was  painful  after  any  exertion. 

In  June  and  July  the  swelling  gradually  increased,  and  the 
mass  extended  over  a  larger  area  approaching  nearer  to  the 
umbilicus,  and  later  a  sensation  of  fluctuation  was  felt,  when  the 
■deep  swelling  became  less  definite,  but  the  surface  swelling  was 
more  obvious  on  inspection.  About  the  middle  of  July  there  was 
a  sudden  decrease  in  the  size  of  the  tumour,  with  some  relief  and 
temporary  improvement.  It  was  at  that  time  that  we  saw  her, 
and  found  a  distinct  tumour  beneath  the  right  costal  margin, 
apparently  adherent  to  the  parietes.  Cholelithiasis  with  suppura- 
tion was  diagnosed,  and  the  question  of  malignant  disease  raised. 


298  SURGERY  OF  THE  STOMACH 

The  stomach  was  markedly  dilated.  On  August  g  a  vertical 
incision  through  the  right  rectus  was  made  on  a  mass  of  adherent 
viscera.  An  abscess  was  found  in  the  sheath  of  the  rectus,  which 
was  cleared  out  and  purified  as  far  as  possible.  The  gall-bladder, 
which  was  very  much  thickened  and  adherent,  was  opened,  when 
some  thick  purulent  discharge  escaped.  General  soiling  of  the 
peritoneum  was  prevented  by  sponge  packing.  A  large  gall-stone 
was  removed  from  the  gall-bladder,  and  another  from  the  cystic 
duct.  A  fistula  was  found  between  the  gall-bladder  and  the 
pyloric  end  of  the  stomach,  through  which  the  empyema  was 
discharging  itself  into  the  stomach. 

The  pylorus  was  found  to  be  much  thickened  and  the  seat  of 
a  nodular  growth,  which  also  invoked  the  gall-bladder  and  adjoin^ 
ing  part  of  the  liver.  Cholecystectomy  was  performed,  and  with 
the  gall-bladder  was  removed  a  V-shaped  portion  of  the  liver,  the 
gaping  edges  in  the  liver  being  brought  together  by  deep  chromi- 
cized  catgut  ligatures,  the  haemorrhage  being  controlled  by  sponge 
pressure.  A  tube  was  placed  in  the  cystic  duct,  which  was  then 
firmly  stitched  round  the  tube,  so  as  to  avoid  the  escape  of  bile. 
Partial  gastrectomy  was  then  performed,  the  cut  section  of  the 
stomach .  being  united  to  the  cut  section  of  the  duodenum  by 
means  of  two  continuous  sutures  around  a  bone  bobbin.  Ari 
omental  graft  was  then  sewn  over  the  junction  to  afford  addi- 
tional security.  As  the  disease  was  clearly  malignant  and  all  the 
growth  within  the  abdomen  had  been  removed,  the  portion  of 
rectus  involved  in  the  disease  and  the  adjoining  peritoneum  were 
excised,  a  further  transverse  incision  being  necessary.  To  close 
the  wound  the  peritoneum,  aponeurosis,  and  muscular  wall  were 
then  securely  closed  layer  by  layer,  the  whole  operation  being 
completed  w^ithin  the  hour. 

The  patient  rallied  well,  and  convalescence  was  uninterrupted. 
Bile  flowed  freely  through  the  tube  until  it  was  removed  on 
August  22  ;  a  gauze  drain  was  then  employed  until  the  wound 
healed.  The  faeces  soon  assumed  a  normal  colour,  and  the  slight 
jaundice  cleared  up.  Microscopic  section  of  the  growth  showed 
it  to  be  columnar-celled  carcinoma.  The  patient  returned  home 
within  the  month,  and  when  she  came  to  see  us  two  months  after 
operation  she  was  then  gaining  strength,  and  had  had  no  return 
of  her  symptoms.  The  general  health  had  much  improved,  and,^ 
beyond  a  slight  sinus  where  the  drainage-tube  had  been  and  the 
scar  of  the  wound,  there  was  no  trace  of  operation.  The  small 
sinus  did  not  discharge  bile,  but  merely  a  few  drops  of  sero-pus 
in  the  day. 

A  report  from  her  medical  man  in  March,  1901,  was  to  the 
eff'ect  that  the  patient  was  in  very  good  health. 


OPERATIONS  UPON  THE  STOMACH  299 

Preliminary  Ligature  of  the  Coronary  and    Gastro-duodenal 

Arteries. 

Cuneo  (These  de  Paris,  1900)  draws  attention  to  the 
advantages  which  result  from  a  prehminary  ligature  of  these 
vessels.  Ligature  of  the  coronary  artery  permits  the  easier 
application  of  a  clamp  to  the  stomach.  Ligature  of  the 
gastro-duodenal  is  effected  after  division  of  the  stomach  at 
its  duodenal  end.  The  cut  ends  of  the  viscera  are  forcibly 
drawn  apart,  and  the  vessel  is  seen  to  occupy  the  depth  of 
this  angle  formed  by  the  meeting  of  the  duodenum  and  the 
pancreas  (sinus  duodeno-pancreaticus).  After  ligature  of  the 
vessel  the  subpyloric  and  retropyloric  glands  are  dissected 
out  from  a  bloodless  area. 

Complete  Gastrectomy. 

This  operation  was  first  performed  in  1883  bv  Connor 
of  Cincinnati.  His  patient,  a  woman  of  lifty  3-ears  of  age, 
died  on  the  table.  \n  1894  Langenbuch  published  two  cases 
of  'resection  of  the  stomach;'  in  each  only  seven-eighths, 
not  the  whole  of  the  stomach,  ^vas  removed.  The  first  com- 
plete gastrectom}-  in  the  human  subject  was  performed  by 
Schlatter  of  Zurich  on  September  6,  1897  5  the  second  by 
C.  B.  Brigham,  of  Boston,  U.S.A.,  on  February  24,  i8g8. 
In  the  former  the  cut  end  of  the  oesophagus  was  united  to  a 
loop  of  the  jejunum,  the  duodenal  openmg  being  closed;  in 
the  latter  the  cut  ends  of  the  oesophagus  and  duodenum  were 
united  over  a  Murphy's  button. 

The  following  account  is  taken  from  Dr.  Schlatter's 
description  {Lancet,  vol.  i.,  1898)  of  the  operation  performed 
by  him  : 

'  After  shutting  off  the  peritoneal  cavity  with  sterilized  com- 
presses, I  isolated  the  stomach  on  its  great  and  small  curvatures, 
separating  the  great  and  small  omentum  with  the  aid  of  Pean's 
clamps,  and  ligaturing  the  clamped  portions  with  silk.  I  then 
pulled  it  firmly  downwards  in  order  to  obtain  access  to  the 
oesophagus.  The  left  lobe  of  the  liver,  which  covered  the  field  of 
operation,  was  held  up  constantly  by  the  hand  of  an  assistant,  in 
which  way  we  succeeded  in  applying  a  W'olfler's   compressorium 


3CO  SURGERY  OF  THE  STOMACH 

to  the  oesophagus  tolerably  high  up.  I  applied  a  Stille's  clamp 
quite  close  to  the  cardiac  border  of  the  tumour,  and  separated  the 
stomach  from  the  oesophagus  just  at  their  point  of  junction.  The 
direction  of  the  incision  happened  to  be  somewhat  oblique,  so  that 
I  found  it  to  be  advantageous  to  reduce  the  aperture  of  the 
oesophagus  by  means  of  a  small  suture.  The  pylorus  was  treated 
in  exactly  the  same  way.  The  duodenum  was  freed  as  far  as 
possible  towards  the  head  of  the  pancreas,  and  the  stomach, 
together  with  the  pylorus,  was  separated  between  a  "  duodenum 
compressorium  "  applied  as  far  away  as  possible,  and  a  tumour 
compressorium  applied  to  the  duodenal  region.  The  aperture  of 
the  portion  of  the  duodenum  which  remained  in  the  abdomen  was 
cleansed  with  pads  of  iodoform  gauze,  just  as  had  been  already 
done  in  the  case  of  the  aperture  of  the  oesophagus.  An  extensive 
portion  on  the  continuity  of  the  digestive  tract  was  now  cut  away. 
I  endeavoured  to  draw  up  the  end  of  the  duodenum  to  the  end  of 
the  oesophagus,  but  it  was  only  with  the  greatest  difficulty  that 
I  could  bring  them  into  contact,  so  that  the  union  of  the  two 
orifices  was  not  to  be  expected.  I  turned  in  the  border  of  the 
duodenum,  and  closed  the  aperture  with  a  double  suture.  Start- 
ing from  the  duodeno-jejunal  angle,  I  followed  the  small  intestine 
downwards  for  about  30  centimetres  (12  inches),  drew  it  out  at 
that  point,  brought  it  across  the  transverse  colon,  and  applied  it 
to  the  end  of  the  oesophagus.  A  piece  of  the  small  intestine 
about  10  centimetres  (4  inches)  long  being  held  in  Wolfler's 
compressors,  the  intestine  was  fixed  to  the  oesophagus  by  sutur- 
ing the  serous  membrane,  after  which  it  was  incised  for  about 
1^  centimetres  (o-6  inch)  in  the  direction  of  its  length,  and  the 
mucous  membrane  of  the  oesophageal  part  was  united  in  its  whole 
circumference  with  the  mucous  membrane  of  the  intestine  by 
means  of  a  continuous  circular  silk  suture.  A  continuous  suture 
in  the  muscular  and  serous  tissue  and  a  Lembert's  interrupted 
silk  suture  were  applied  over  the  suture  of  the  mucous  tissue. 
The  compressors  on  the  small  intestine,  as  well  as  the  one  in  the 
extremity  of  the  oesophagus,  which  latter  had  been  in  position 
more  than  two  hours,  were  removed.  When  returned  to  the 
peritoneal  cavity,  the  sutured  parts  retracted  themselves  upwards 
with  some  force  to  the  place  where  the  oesophagus  traverses  the 
diaphragm.  The  abdominal  walls  were  closed.  The  anaesthesia 
(8  fluid  ounces  of  ether)  progressed  quietly.  The  pulse  after  the 
operation  was  regular,  tolerably  full,  and  96  per  minute.' 

'  The  patient  recovered  from  the  operation,  and  lived  until 
October  29,  1898.  At  the  autopsy  the  mesenteric,  retroperi- 
toneal, bronchial  and  supraclavicular  lymphatic  glands  were 
found  enlarged,  and  secondary  deposits  were  found  in  the  pleurae. 


OPERATIONS  UPON  THE  STOMACH  301 

The  following  is  an  abstract  of  Brigham's  case  : 

On  opening  the  abdomen  the  tumour  was  found  to  comprise 
nearly  half  of  the  wall  of  the  stomach  ;  there  was  no  marked 
glandular  involvement  or  adhesions,  and  it  was  decided  to  remove 
the  whole  organ.  The  greater  and  lesser  omenta  were  tied  off 
and  divided,  the  duodenum  was  clamped,  and  a  ligature  was  placed 
around  it  \  inch  above  the  clamp,  and  the  tissues  were  divided 
between  the  two.  The  ends  were  washed  in  salt  solution  and 
wrapped  in  iodoform  gauze.  The  same  method  was  employed 
with  the  oesophagus  and  the  cardiac  end  of  the  stomach.  It  was 
found  that  the  oesophagus  and  duodenum  could  be  brought 
together,  and  they  were  united  by  a  Murphy  button  to  shorten 
the  operation,  as  the  patient  was  growing  weak.  No  Lembert 
sutures  were  used,  as  the  approximation  was  good.  The  operation 
lasted  two  and  a  quarter  hours,  and  was  followed  by  considerable 
shock.  At  the  end  of  six  weeks,  when  the  report  of  the  case 
was  made,  the  patient  was  quite  well,  enjoyed  her  food,  and  was 
gaining  in  weight.  Never  after  the  operation  was  any  undigested 
food  found  in  the  faeces. 

These  cases  illustrate  the  two  possible  methods  of  dealing 
with  the  cut  ends  of  the  oesophagus  and  duodenum  after 
the  stomach  has  been  excised.  The  method  employed  by 
Brigham  is  theoretically  the  better,  for  when  an  end-to-side 
anastomosis  is  performed,  food  might  conceivably  pass  from 
the  oesophagus  into  the  proximal  part  of  the  jejunum,  and, 
there  permanently  lodging,  set  up  ulceration  and  perfora- 
tions. 

Results  of  Partial  Gastrectomy. 

We  do  not  think  that  any  useful  purpose  can  be  served  by 
quoting  the  statistics  of  the  earlier  cases  of  pylorectomy. 
The  mortality  was  enormous  ;  the  experience  gained,  how- 
ever, was  invaluable.  In  order  to  obtain  a  fair  estimate  of 
the  risks  and  successes  of  an  operation  so  rarely  performed, 
it  is  essential  that  we  should  select  only  those  operators  who 
publish  all  their  cases,  ignoring  the  isolated  successful  cases 
recorded  from  time  to  time  in  the  journals.  The  Continental 
surgeons  chiefly  afford  us  the  information  necessary. 

Kronlein  {Archiv.  f.  Klin.  Chir.,  i8g8,  p.  447)  records  all 
his   cases   of  partial   excision,  and   his   assistant   Schlatter's 


302  SURGERY  OF  THE  STOMACH 

case  of  total  extirpation,  of  the  stomach.  Of  24  cases, 
5  died  ;  of  the  first  4  resections  3  died  (1881-1888),  of  the 
following  20  only  2  died  (1888-1898).  The  after-history  of 
the  ig  patients  who  recovered  is  as  follows  :  2  died  of 
intercurrent  disease  (heart  failure,  pneumonia)  wathin  four 
months,  without  recurrence ;  8  died  of  recurrent  growth, 
2  in  the  first  year,  4  in  the  second  year,  and  2  in  the  third 
year.  The  average  duration  of  life  in  these  8  cases  was 
507  days.  Eight  patients  were  alive  in  July,  i8g8,  without 
recurrence  ;  6  in  the  first  year  and  2  in  the  fourth  year  ; 
I  case  was  living  with  a  recurrent  growth  (Schlatter's  case 
died  thirteen  and  a  half  months  after  operation). 

Maydl  {Medical  Press,  October,  1899)  records  25  operations 
for  carcinoma  of  the  stomach  ;  4  patients  died,  directly  or 
indirectly,  as  the  result  of  the  operation  in  two,  three,  and 
five  days,  and  from  embolic  gangrene  of  right  leg  ;  7  patients 
recovered  from  the  operation  and  left  the  hospital,  but 
suffered  from  a  return  of  the  growth  within  a  short  period. 
The  average  duration  of  life  was  11*7  months.  Fourteen 
patients  were  alive  at  the  time  of  the  report ;  of  these,  7  had 
lived  for  over  two  years,  averaging  four  years  two  and  a  half 
months  each,  and  7  had  lived  for  under  two  years. 

Kocher  {Korrespondenzhlatt  fur  Schweizer  Aerzte,  1898)  has 
resected  the  pyloric  end  of  the  stomach  57  times,  with 
5  deaths.  Eight  cases  are  considered  as  cured.  One,  a 
woman,  was  alive  ten  years  after  operation,  another  five 
years,  another  three  years,  another  two  and  a  half  years. 
Four  patients  died  over  three  years  after  the  operation  from 
other  causes. 

Rydygier  (Deut.  Zeitschr.  fur  Chirurgie,  January,  1901) 
relates  all  the  stomach  operations  he  has  performed  in  the 
last  twenty  years.  There  are  25  partial  gastrectomies.  Of 
these,  8  recovered  and  17  died.  The  causes  of  death  are  : 
Pneumonia,  5  cases  ;  septic  peritonitis,  2  cases ;  shock  and 
collapse,  5  cases ;  in  5  the  cause  is  not  stated.  Rydygier 
resects  a  large  portion  of  the  stomach  for  limited  tumour, 
cutting  at  least  5  to  10  centimetres  beyond  the  apparent 
confines  of  the  growth. 

Czerny  {Beitr.  zur  Klin.   Chir.,  1899,  p.   18,  and  Archiv. 


OPERATIONS  UPON  THE  STOMACH  303 

/.  Klin.  Chir.,  i8g8,  p.  459)  has  performed  29  partial  gastrec- 
tomies since  1881.  Of  these  11  died.  Of  the  survivors, 
one  has  hved  7  years,  one  32-  years,  and  in  others  hfe  was 
prolonged  from  3  to  31  months.  The  average  duration  of 
life  after  operation  was  22  months. 

Mr.  Rutherford  Morison,  of  Newcastle,  has  kindly  favoured 
us  with  the  details  of  all  his  cases  of  partial  gastrectomy. 
There  are  16  cases.  Of  these,  7  died  within  a  month  of 
operation — 4  days,  14  days,  a  few  hours,  6  days,  29  hours, 
8  days,  and  14  hours ;  9  recovered  from  the  operation,  and 
lived  7  weeks,  2>7  months,  26  months,  19  months,  6  months, 
2  months,  and  7  months  ;  2  are  still  living  without  recur- 
rence :  I  was  operated  upon  in  October,  1898,  and  i  in 
October,  1900. 

Results  of  Complete  Gastrectomy. 

Twelve  cases  of  complete  gastrectom}^  have  been  recorded, 
with  the  following  results  : 

T.  The  patient  died  on  the  table.     (Connor.) 

2.  Lived  14  months.     (Schlatter.) 

3.  Alive  and  well  2  years  after  operation.     (Brigham.) 

4.  Alive  and  well  17  months  after  operation.     (Delatour.) 

5.  Died  II  months  after  of  recurrence.     (Richardson.) 

6.  Alive   and   well    18    months    after   operation.      (Mac- 

donald.) 

7.  Death.     (Chavasse.) 

8.  Death  on  the  table.     (Noble.) 

g.   Died  36  hours  after  operation.      (Bernays.) 

10.  Stomach,  first  portion  of  duodenum  and  a  portion  of 

pancreas  removed.      Patient  alive  11  months  after 
operation.     (Ricord.) 

11.  Recovery.     Recently  performed.     (Boeckel.) 
:2.   Recovery.     Recently  performed.     (Harvie.) 

Thus,  of  12  patients,  4  died  as  a  result  of  the  operation. 
Of  those  that  survived,  the  earliest  death  was  11  months 
after  operation.  The  cases  are  too  recent  for  any  pro- 
nounced opinion  to  be  passed,  but  the  results  may,  we  con- 
sider, be  looked  upon  as  surprisingly  good  and  as  a  happy 
augury  for  future  extensive  and  radical  measures. 


304  SURGERY  OF  THE  STOMACH 

Jejunostomy. 

JeJLinostomy  is  an  operation  that  can  be  but  rarely  called 
for.  It  is  suitable  only  for  those  patients  suffering  from 
ad\anced  disease,  in  whom,  owing  to  the  position,  or  extent, 
or  character  of  the  growth,  gastro-enterostomy  is  deemed 
imprudent  or  impossible.  Maydl  has  recorded  22  cases, 
with  4  deaths,  as  the  result  of  the  operation.  His  method 
is  as  follows :  The  abdomen  being  opened,  the  upper  part  of 
the  jejunum  is  sought.  When  found  it  is  divided  completely, 
the  proximal  end  stitched  to  the  side  of  the  distal,  and  the 
distal  brought  up  to  the  abdominal  wall.  Probably  a  safer, 
certainly  a  quicker,  operation  would  be  one  (performed  on 
one  occasion  by  Moynihan,  Lancet,  April  27,  igoi)  planned 
after  the  method  of  Witzel  for  gastrostomy.  The  upper 
portion  of  the  jejunum  being  exposed,  by  an  incision  through 
the  left  rectus  muscle  a  small  incision  is  made  in  the  gut  and 
an  indiarubber  tube  equal  to  a  No.  10  or  12  catheter  fixed  in 
by  a  single  stitch.  The  tube  is  then  enfolded  on  the  wall  of 
the  intestine  towards  the  duodenum  and  buried  by  a  layer  of 
sutures.  A  few  additional  sutures  secure  the  jejunum  to  the 
abdominal  wall,  and  the  wound  is  finally  closed  round  the 
tube.     The  patient  can  be  fed  immediately. 

Although  the  operation  is  so  rarely  called  for,  it  is,  never- 
theless, one  that  should  be  borne  in  mind,  as  in  an  appro- 
priate case  it  confers  a  great  boon  upon  the  patient, 
and  renders  tolerable  an  otherwise  comfortless  existence. 
Schlatter's  case  of  oesophago-jejunostomy  after  total  resec- 
tion of  the  stomach  showed  that  a  patient  could  thrive  and 
increase  in  weight  upon  food  which  was  introduced  into  the 
intestine  at  almost  the  same  point  as  in  jejunostomy,  per- 
formed by  the  above  method.  The  following  is  an  account 
of  a  case  operated  upon  by  Mayo  Robson  in  i8gi  : 

Extensive  Caxxer  of  Stomach,  with  Inability  to  retain 
Food.  Jejunostomy;  Recovery  from  Operation  ;  Death 
FROM  Progress  of  Disease  at  End  of  Two  Months. 

Mrs.  E.  B.,  aged  fifty-eight,  residing  in  Lincolnshire,  was  sent 
on  June  ig,  1891,  by  Dr.  Hamilton  of  Crowle,  on  account  of  an 
abdominal  tumour,  accompanied  by  persistent  vomiting  and  rapid 


OPERATIONS  UPON  THE  STOMACH  305 

loss  of  flesh.  The  patient  said  that  she  had  been  quite  well  until 
a  year  and  a  half  before  admission,  when  she  was  suddenly 
attacked  with  vomiting,  which  had  continued  ever  since.  She 
had  lost  weight  from  that  time,  until  on  admission  she  was  worn 
almost  to  a  skeleton.  She  had  never  had  hsematemesis.  The 
vomiting  took  place  directly  after  food,  and  was  unaccompanied 
by  nausea.  At  the  beginning  she  had  a  stabbing  pain  after  food 
in  the  region  of  the  left  breast,  but  during  the  six  months  before 
admission  the  pain  had  been  continuous,  and  always  worse  after 
eating.  About  three  months  before  admission  she  first  noticed  a 
swelling  in  the  left  hypochondrium,  which  had  increased  rapidly 
up  to  the  time  of  admission.  From  the  time  the  tumour  was 
noticed  the  pain  always  seemed  to  radiate  from  it. 

On  admission  the  patient  was  extremely  emaciated,  and  vomited 
everything  immediately  after  eating.  The  vomit  consisted  simply 
of  what  she  had  taken,  and  contained  free  hydrochloric  acid,  but 
no  sarcinse  or  blood  cells  could  be  detected  microscopically. 
Occupying  the  left  hypochondrium,  and  reaching  into  the  epigas- 
trium, was  a  hard  nodular  tumour,  moving  up  and  down  with 
respiration,  the  skin  being  quite  movable  over  it.  A  tumour 
could  also  be  felt  beneath  the  liver,  which  was  diagnosed  as  a 
distended  gall-bladder. 

Cancer  of  the  stomach  was  diagnosed,  and  the  patient  was  fed 
with  small  quantities  of  Brand's  essence  and  peptonized  foods, 
nutrient  enemata  being  also  administered.  The  pain  was  con- 
trolled by  morphia. 

At  first  slight  improvement  took  place,  but  towards  the  end  of 
the  month  she  again  lost  ground,  and  the  vomiting  still  persisted. 
After  consultation,  an  exploratory  incision  was  decided  on,  in 
order  to  see  if  the  disease  could  be  removed ;  but  if  it  should 
prove  too  extensive  for  removal,  as  it  was  suspected  it  might, 
jejunostomy  could  be  done. 

On  July  I,  1891,  the  A.C.E.  mixture  being  the  anaesthetic 
and  the  skin  of  the  abdomen  having  been  asepticized,  an  incision 
of  3  inches  was  made  in  the  linea  alba  above  the  umbilicus,  ex- 
posing the  tumour,  which  was  found  to  be  occupying  the  whole 
of  the  anterior  wall  of  the  stomach,  and  therefore  incapable  of 
removal.  There  was  also  a  distended  gall-bladder,  containing 
gall-stones. 

The  jejunum  was  then  found  at  its  fixed  point  on  the  left  of 
the  spine,  and  traced  for  about  6  inches  downwards,  at  which 
spot  a  knuckle  of  the  bowel  was  brought  forward  and  fixed  by 
loop  sutures  (after  the  parietal  peritoneum  and  skin  had  been 
connected  by  a  continuous  suture),  in  the  way  suggested  for 
gastrostomy   by   ^Ir.   Greig    Smith,   and   which    a    case    of   ours 

20 


3o6  SURGERY  OF  THE  STOMACH 

published  in  the  Byitish  Medical  Jonvnal  for  June  7,  1890,  proves 
to  be  a  safe  and  efficient  method. 

A  loop  of  silver  wire  was  first  inserted  into  the  convex  surface 
of  the  bowel  at  a  spot  where  it  would  have  to  be  opened.  A 
round,  large-eyed  sewing  needle  was  then  threaded  with  12  inches 
of  silk  of  medium  thickness,  and  passed  under  the  peritoneal  coat 
of  the  intestine  in  a  circle  about  i^  inches  in  diameter,  the  suture 
being  made  to  emerge  and  leave  five  loops  at  equal  intervals. 
The  loops  were  drawn  through  the  parietes  at  about  \  inch  from 
the  margin  of  the  wound.  As  each  loop  was  drawn  up,  a  piece 
of  No.  6  catheter  was  passed  through  it,  and  when  all  were  in 
position  the  ends  of  the  silk  were  drawn  in  and  the  loops  tight- 
ened over  the  catheter,  over  which  the  two  ends  were  then 
knotted ;  the  silver  wire  was  then  fixed  under  the  catheter,  and 
a  few  sutures  connected  the  bowel  to  the  skin.  The  rest  of  the 
parietal  incision  was  brought  together  by  interrupted  silkworm- 
gut  sutures  in  the  ordinary  way. 

On  the  following  day  the  patient  felt  quite  comfortable,  and 
was  fed  by  the  rectum  entirely.  This  was  continued  until  July  7, 
when  a  small  opening  was  made  in  the  exposed  bowel  with  a 
tenotomy  knife,  and  a  soft  catheter  was  passed  in,  through  which 
she  was  fed  by  peptonized  food,  of  which  she  w^as  able  to  take 
two  or  three  pints  a  day.  She  gained  flesh,  and  Avas  able  to 
return  home  on  July  27.  Her  chief  trouble  was  that  the  skin 
around  the  artificial  opening  became  irritable  ;  but  through  the 
opening  into  the  duodenum  she  continued  to  be  able  to  take  a 
fair  quantity  of  food,  which  was  well  retained.  The  original 
disease  continued  to  advance,  and  after  two  months  she  died 
from  exhaustion. 

No  autopsy  could  be  obtained. 


INDEX 


A 
Adenoma  of  the  stomach,  52 
Adhesions  in  cases  of  ulcer,  128 
Anatomy  of  the  stomach,  i 
Auscultation,  11 

B. 

Bacteriology  of  perforating  ulcer,  152 

Bernay's  operation,  34 

Blood  in  cancer,  70 

Bobbin,  Mayo  Robson's  bone,  253 

C. 

Cancer,  60 

choice  of  operation  in,  78 

diagnosis,  75 

prolongation  of  life  in,  79 

conditions  of  patients  after  opera- 
tions for,  79 

implantation  upon  ulcer,  73 
Cardiac  orifice,  dilatation  of,  33 
Congenital  atresia  of  the  pylorus,  44 

stenosis  of  the  pylorus,  36 

D. 
Diagnosis  in  stomach  diseases,  7 
Dilatation  of  the  stomach,  194 
acute,  210 

post-operative,  216 
atonic,  217 
causes  of,  195 
Duodenum,  implication  of,  in  cancer, 
63 

E. 
Erosions  of  the  stomach,  89 
Examination,  methods  of,  7 
Exploratory  incisions,  iS 
Extension  of  cancer,  61 

F. 
Fibromyoma  of  the  stomach,  56 
Fistula,  gastric,  233 
Foreign  bodies  in  the  stomach,  24 
Frank's  operation,  gastrostomy,  255 


G. 

Gastrectom}-,  partial,  289 

complete,  299 

results  of,  301 
Gastro-enterostomy,  268 

after-effects,  274 

changes  in  the  stomach  after,  277 

contraction  of  orifice,  275 

regurgitant  vomiting,  274 

results  of,  278 
Gastro-gastrostomy,  265 
Gastropexy,  Duret's  operation,  240 

Stengel   and   Beyea's   operation, 
241 
Gastroplication,  218 
Gastroptosis,  239 
Gastrorrhagia,  130 
Gastrostomy,  255 
Gastrotomy,  22 
Glands  of  the  stomach,  62 
Gunshot  wounds  of  the  stomach,  48 

H. 
Hahn's  operation,  32 
Hsematemesis,  130 

post-operative,  133 
treatment  of,  136 
vessels  affected,  136 
Hour-glass  stomach,  173 
forms  of,  189 
treatment  of,  190 
Hydrochloric  acid,  absence  in  cancer, 
72 
determination  of,  17 

I 

Injury  of  the  stomach,  45 
from  within,  48 

J- 

Jejunostomy,  304 

K. 

Kader's  operation,  gastrostomy,  259 
Kocher's   operation,    partial   gastrec- 
tomy, 292 


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Vol.    1. — Diseases    of  the  Nose  and   Naso-Pharynx.     8vo,   670  pages,   4  colored 
plates  and  182  wood-cuts.     Extra  muslin,  $4.00  net. 

Vol.  II. — Diseases  of  the  Throat.  8vo,  832  pages,  3  colored  plates,  and  125  wood- 
cuts.    Extra  muslin,  S4.00  net. 

Bodenhamer,  William,  M.D., 

Professor  of  the  Diseases,  Injuries,  and  Malformations  of  the  Rectum,  Anus,  and  Genito-Urinary 
Organs. 

AN  ESSAY  ON  RECTAL  MEDICATION.  One  volume,  8vo,  58 
pages,  illustrated,  muslin,  $1.00  net. 


PUBLICATIONS   OF   WILLIAM   WOOD    &   COMPANY. 


Bollinger,  Dr.  O.,  Obermedicinalrat  and  Professor. 

ATLAS  AND  ESSENTIALS  OF  PATHOLOGICAL  ANATOMY. 
Volume  I.  Circulatory,  Respiratory,  and  Digestive  Apparatus,  including 
the  Liver,  Bile  Ducts,  and  Pancreas.  With  69  colored  figures  upon  60 
plates  and  18  illustrations  in  the  text.  Muslin.  Price,  $1.50  net. 
(  Wood's  Medical  Hand  Atlases.) 

ATLAS  AND  ESSENTIALS  OF  PATHOLOGICAL  ANATOMY. 
Volume  II.  Urinary  Apparatus,  Genital  Organs,  Nervous  System,  Bones. 
With  65  colored  figures  upon  52  full-page  plates  and  16  illustrations  in 
the  text.     Muslin.     Price,  $1.50  }iet.    (Wood's  Medical  Hand  Atlases.) 

Bowhill,  Thomas,  F.R.CV.S.,  F.R.P.S.,  Edinburgh. 

A  MANUAL  OF  BACTERIOLOGICAL  TECHNIQUE  AND 
SPECIAL  BACTERIOLOGY.  One  volume  of  296  pages,  octavo,  pro- 
fusely illustrated  by  numerous  engravings,  exquisite  half-tones,  and  four 
superb  photogravure  plates  of  six  figures  each.     Extra  muslin,  $4.50  net. 

Bradford,  Edward  H.,  M.D., 

Surgeon  to  the  Children's  Hospital  and  the  Samaritan  Hospital ;  Assistant  Professor  of  Ortho- 
pedic Surgery,  Harvard  Medical  School ;  and 

Lovett,  Robert  W.,  M.D., 

Assistant  Surgeon  to  the  Children's  Hospital;  Sui-geon  to  the  Infants'  Hospital. 

A  TREATISE  ON  ORTHOPEDIC  SURGERY.  Second  Revised 
Edition.  One  volume  of  661  pages,  8vo,  illustrated  by  621  engravings. 
Muslin,  $4.50  net. 

Bramwell,  Byrom,  M.D.,  F.R.C.P.  Ed.,  F.R.S.  Ed. 

DISEASES  OF  THE  SPINAL  CORD.  Third  Edition.  Illustrated 
by  170  engravings  in  black  and  numerous  colors.  In  this  edition 
the  subject  matter  has  been  thoroughly  revised  and  greatly  extended  ; 
in  fact,  the  text  has  been  entirely  rewritten  and  rearranged  in  lecture 
form.  A  large  number  of  new  illustrations — chiefly  clinical — have 
been  added.     Extra  muslin,  octavo,  671  pages,  $4.00  net. 

Brass,  Dr.  Arnold, 

Gottingen. 

ATLAS  OF  HUMAN  HISTOLOGY.  Sixty  full-page  plates,  engraved 
and  superbly  printed  in  many  colors,  with  explanatory  notes.  An  ex- 
quisite work.  Authorized  translation  from  the  German,  with  additions. 
By  R.  A.  Young,  M.D.,  B.Sc.  Lond.     Extra  buckram,  in  box,  $10.00  net. 

Broadbent,  Sir  William  H.,  Bart.,  M.D.  Lond.,  F.R.5., 

F.R.C.P.,        and 

Broadbent,  John  F.  H.,  M.A.,  M.D.  (Oxon.),M.R.C.P. 

HEART  DISEASE,  WITH  SPECIAL  REFERENCE  TO  PROG- 
NOSIS AND  TREATMENT.  Second  Edition.  One  volume  of  432 
pages,  8vo,  illustrated  by  a  colored  plate  and  by  engravings.  Muslin, 
$4.00  net. 


4  PUBLICATIONS   OF   WILLIAM    WOOD   &   COMPANY. 

Brouardel,  P.,  M.D.  Paris. 

DEATH  AND  SUDDEN  DEATH.  Translated  by  F.  Lucas  Ben- 
ham,  M.D.,  B.S.  Lond.     One  volume,  8vo,  280  pages,  muslin,  $2.50  net. 

Buck,  Albert  H.,  H.D., 

Clinical  Professor  of  the  Diseases  of  the  Ear,  in  the  College  of  Physicians  and  Surgeons,  New  York; 
Consulting  Aural  Surgeon,  New  York  Eye  and  Ear  Infirmary. 

A  TREATISE  ON  DISEASES  OF  THE  EAR.  Together  with  a 
Brief  Sketch  of  the  Anatomy  and  Physiology  of  this  Organ.  Third 
Revised  Edition.  One  volume  of  604  pages,  octavo,  profusely  illus- 
trated by  147  wood-engravings.     Extra  muslin,  $3.50  net. 

A  VEST-POCKET  MEDICAL  DICTIONARY.  Embracing  those 
terms  and  abbreviations  which  are  commonly  found  in  the  medical  liter- 
ature of  the  day,  but  excluding  names  of  drugs  and  many  words  which 
may  more  properly  be  found  in  a  general  dictionary  of  the  English  lan- 
guage. A  most  complete  little  book  of  536  pages,  less  than  one-half 
inch  in  thickness,  32mo,  bound  in  flexible  leather.     Price,  $1.00  net. 

Cabot,  Richard  C,  M.D., 

Boston,  Mass. 

A  GUIDE  TO  THE  CLINICAL  EXAMINATION  OF  THE  BLOOD 
FOR  DIAGNOSTIC  PURPOSES.  Fourth  edition.  One  volume  of 
500  pages,  octavo,  illustrated  by  numerous  wood-engravings  and  by 
chromo-lithographic  plates,  muslin,  $3.25  net. 

THE  SERUM  DIAGNOSIS  OF  DISEASE.  This  book  aims  to  bring 
together  in  convenient  form  the  results  of  the  immense  amount  of 
work  which  has  been  done  upon  serum  diagnosis  since  1896.  In  one 
octavo  volume  of  154  pages,  illustrated.     Price,  $1.50  net. 

PHYSICAL  DIAGNOSIS  OF  DISEASES  OF  THE  CHEST.  i2mo, 
326  pages.  Beautifully  illustrated  by  half-tone  cuts,  and  one  full-page 
plate.      Muslin,  $2.50  net. 

Campbell,  Harry,  M.D.,  B.S.  Lond.  (London). 

RESPIRATORY  EXERCISES,  in  the  Treatment  of  Disease,  Notably 
of  the  Heart,  Lungs,  Nervous  and  Digestive  Systems.  An  essentially 
practical  work,  dealing  with  a  means  of  therapy  which  is  not  always 
appreciated  at  its  full  value.  One  volume  of  208  pages,  8vo,  muslin, 
$2.00  7iet. 

Carpenter,  George,  M.D., 

Physician  to  the  Evelina  Hospital  for  SicK  Children,  London. 

THE  SYPHILIS  OF  CHILDREN  IN  EVERY-DAY  PRACTICE. 
i2mo,  112  pages,  illustrated.     Muslin,  $1.25  net. 

Carpenter,  Wm.  B.,  C.B.,  fl.D.,  LL.D. 

THE  MICROSCOPE  AND  ITS  REVELATIONS.  8vo.  Vol.  L, 
388  pages;  Vol.  II.,  354  pages.  One  colored,  twenty-six  plain  plates, 
and  five  hundred  and  two  wood-engravings.  Two  volumes  in  one. 
Muslin,  $3.00  net. 


PUBLICATIONS   OF   WlLIJAM    WOOD   &   COMPANY.  5 

Clarke,  A.  Campbell,  M.D.,  F.F.P.S.Q., 

Mackintosh  Lecturer  on  Psychological  Medicine,  St.  Mungo's  College,  Glasgow;  Medical  Superintend- 
ent of  Lanark  County  Asylum,  Hartwood. 

CLINICAL  MANUAL  OF  MENTAL  DISEASES  FOR  PRACTI- 
TIONERS AND  STUDENTS.  One  volume,  502  pages,  illustrated, 
muslin,  $3.50  net. 

Clarke,  J.  Jackson,  M.B.  Lond.,  F.R.C.S., 

Surgeon  to  Out-Patients  at  the  North- West  London  and  City  Orthopaedic  Hospitals,  etc. 

ORTHOPEDIC  SURGERY,  a  text-book  of  the  Pathology  and  Treat- 
ment of  Deformities.  One  volume,  8vo,  473  pages,  illustrated  by  309 
illustrations.     Price,  $3.00  «^^'. 

Coleman,  Warren,  M.D., 

Professor  of  Materia  Medica,  Cornell  University  Medical  School,  etc.,  etc. 

A  SYLLABUS  OF  MATERIA  MEDICA.  This  book  is  an  attempt  to 
assist  the  memory  as  much  as  possible  by  condensing  the  facts,  repeat- 
ing the  doses,  and  by  grouping  the  drugs  in  various  ways.  It  is  in- 
tended to  supplement,  not  to  take  the  place  of,  other  and  larger  works 
on  the  subject.     One  volume,  i2mo,  175  pages.     Price,  $1.00  net. 

Collins,  Joseph,  M.D., 

Professor  of  Nervous  and  Mental  Diseases  in  the  New  York  Post-Graduate  Medical  School  ;  Visiting 
Physician  to  the  New  York  City  Hospital. 

THE  TREATMENT  OF  DISEASES  OF  THE  NERVOUS  SYSTEM  : 
A  HANDBOOK  FOR  PRACTITIONERS.  One  volume  of  616 
pages,  8vo,  illustrated.     Muslin,  $5.00  net. 

Cory,  Robert,  M.A.,  M.D.  Cantab.,  F.R.C.P.  Lond., 

Physician-in-Charge  of  the  Vaccination  Department  of  St.  Thomas'  Hospital  ;  Teacher  of  Vaccina- 
tion in  the  University  of  Cambridge,  etc. 

LECTURES  ON  THE  THEORY  AND  PRACTICE  OF  VACCINA- 
TION.  122  pages,  14  full-page  colored  plates,  muslin.   Price,  $3.25  net. 

Cowen,  Richard  J.,  L.R.C.S.L.,  L.R.C.P.I.,  etc.,  Lon- 
don, Eng. 

ELECTRICITY  IN  GYNECOLOGY.  Small  octavo,  140  pages,  illus- 
trated.    Muslin,  $1.50  net. 

Craig,  Charles  F.,  M.D., 

Assistant  Surgeon  U.  S.  Army. 

ESTIVO-AUTUMNAL  MALARIA.     One  volume,  8vo.     In  Press. 

Dana,  Charles  L.,  A.M.,  M.D., 

Professor  of  Nervous  and  Mental  Diseases  in  the  New  York  Post-Graduate  Medical  School,  and  la 
Dartmouth  Medical  College ;  Visiting  Physician  to  Bellevue  Hospital,  etc. 

TEXT-BOOK  OF  NERVOUS  DISEASES.  Being  a  Compendium  for 
the  Use  of  Students  and  Practitioners  of  Medicine.  Fifth  edition, 
revised  and  enlarged.     8vo,  650  pages,  230  illustrations,  $3.50  net. 


PUBLICATIONS   OF    WILLIAM    WOOD   &   COMPANY 


Delafield,  Francis,  M.D., 

-  Professor  of  Pathology  and  Practical  Medicine,  College  of  Phj'sicians  and  Surgeons,  New  York. 

STUDIES  IN  PATHOLOGICAL  ANATOMY.  Volume  I.,  treating 
of  the  following  subjects  :  Phthisis,  Peritonitis,  Pleurisy,  Pneumonia, 
Empyema,  Hydrothorax,  Bronchitis,  and  Tuberculosis.  Illustrated 
with  ninety-three  full-page  and  double-page  plates  made  by  the  follow- 
ing processes  :  Wood-engravings  of  Original  Drawings  on  the  Block, 
Etchings  on  Copper,  Lithographs  from  Original  Drawings  on  the  Stone, 
and  Photographs  of  Specimens.  Royal  8vo,  bound  in  half  morocco, 
gilt  top,  plates  hinged  on  linen  guards,  $20.00  net. 

"Volume  II.:  Broncho-Pneumonia,  Chronic  Phthisis,  Lobar  Pneumonia, 
Acute  Bright's  Disease,  Chronic  Bright's  Disease.  Illustrated  with  one 
hundred  and  thirty-three  full  and  double-page  plates  hinged  on  linen 
guards,  similar  to  those  of  Vol.  I.  Royal  8vo,  bound  in  half  morocco, 
gilt  top,  $20.00  net. 

Delafield  and 

Prudden,  T.  flitchell,  n.D., 

Professor  of  Pathology  and  Director  of  the  Laboratories  of  Histology,  Pathology,  and  Bacteriology- 
College  of  Physicians  and  Surgeons,  Columbia  College,  New  York. 

A  HANDBOOK  OF  PATHOLOGICAL  ANATOMY  AND  HISTOL- 
OGY. With  an  Introductory  Section  on  Post-Mortem  Examinations 
and  the  Methods  of  Preserving  and  Examining  Diseased  Tissues.  Sixth 
Edition,  entirely  rewritten  and  enlarged.  One  volume  of  838  pages, 
royal  8vo,  illustrated  by  453  engravings  in  black  and  many  colors,  and 
II  chromo-lithographic  and  other  full-page  plates.  Muslin,  $5.00  net; 
leather,  $5.75  net. 

De  Meric,  H.,  Paris. 

DICTIONARY  OF  MEDICAL  TERMS.  (English-French.)  This 
is  the  first  part  of  the  work,  which  is  completed  by  the  publication 
of  the  second  part:  "French-English  Medical  Terms."  It  can- 
not fail  to  be  of  the  greatest  value  to  all  who  have  occasion  for 
such  a  book  The  two  volumes  will  be  sold  separately  at  $1.75 
net^  or  together  at  $3.00  net.  One  volume  of  402  pages,  octavo. 
Muslin,  $1.75  net. 

DICTIONNAIRE  DES  TERMES  DE  MEDECINE.  (Frangais- 
Anglais.)  This  is  the  second  part  of  the  work — one  volume  of  248  pages, 
octavo.     Muslin,  $1.75  net.     The  two  parts  together  at  $3.00  net. 


Draper,  John  C,  M.D.,  LL.D., 


Professor  of  Chemistry  in  the  Medical  Department,  University  of  New  Y'ork,  and  of  Physiology 
and  Natural  History  in  the  College  of  the  City  of  New  York. 

A  PRACTICAL  LABORATORY  COURSE  IN  MEDICAL  CHEM- 
ISTRY. One  volume  of  80  pages,  printed  on  one  side  only,  oblong, 
for  laboratory  use.     Muslin,  $1.00  net. 

Dwight,  Thomas,  A.fl.,  fl.D., 

•  Instructor  in  Topographical  Anatomy  and  Histology  in  Harvard  University ;    Fellow    of    the 
American  Academy  of  Arts  and  Sciences  ;  Surgeon  at  Carney  Hospital. 

FROZEN  SECTIONS  OF  A  CHILD.  Fifteen  full-page  lithographic 
plates,  drawings  from  nature  by  H.  P.  Quincy,  M.D.  One  volume, 
royal  8vo,  66  pages,  muslin,  $2.50  net. 


PUBLICATIONS   OF   WILLIAM   WOOD   &  COMPANY.  7 

Eccles,  A.  Symons,  M.B.,  London. 

Member  Royal  College  of  Surgeons,  England  ;    Fellow  Royal  Medical  and  Chirurgical  Society,  etc. 

THE  PRACTICE  OF  MASSAGE  ;  THE  PHYSIOLOGICAL  EF- 
FECTS AND  THERAPEUTIC  USES.  One  volume,  8vo,  386 
pages,  $2.50  net. 

DIFFICULT  DIGESTION  DUE  TO  DISPLACEMENTS.  One  vol- 
ume, octavo,  illustrated.     Extra  muslin,  $1.25  net.- 

Eccles,  W.  McAdam,  M.S.  Lond.,  F.R.C.S.  Eng. 

HERNIA:  Its  Etiology,  Symptoms,  and  Treatment.  With  many 
illustrations,  including  38  full- page  plates.  One  volume,  octavo,  245 
pages.     Muslin,  $2.50  net. 

Einhorn,  Max,  M.D., 

Adjunct  Professor  Clinical  Medicine,  New  York  Post-Graduate  Medical  School ;  Visiting  Physician 
to  the  German  Dispensary,  and  to  the  Montefiore  Home  for  Chronic  Invalids. 

DISEASES  OF  THE  STOMACH.  Second  revised  edition.  Complete 
in  one  volume  of  502  pages,  post-octavo  (uniform  with  other  volumes 
of  the  Medical  Practitioners'  Series).  Muslin,  $3.25  net;  flexible 
morocco,  $3.75  net. 

DISEASES  OF  THE  INTESTINES.  A  Text-Book  for  Practitioners 
and  Students  of  Medicine.  One  volume  of  408  pages,  small  octavo 
(Medical  Practitioners'  Library),  illustrated.     Extra  Muslin,  $3.00  net. 

Ewart,    William,     M.D.     Cantab.,     F.R.C.P.    Lond., 
M.R.C.S.  Eng., 

Physician  to  St.  George's  Hospital,  and  to  the  Belgrave  Hospital  for  Children  ;  formerly  Assistant 
Physician  and  Pathologist  to  the  Brompton  Hospital  for  Consumption,  etc.,  etc. 

GOUT  AND  GOUTINESS  AND  THEIR  TREATMENT.  One 
volume  of  601  pages,  8vo,  muslin,  $4.00  net. 

Finger,   Ernest,  fl.D., 

Decent  at  the  University  of  Vienna. 

GONORRHOEA:  being  the  translation  of  "  Blennorrhoea  of  the  Sexual 
Organs  and  its  Complications."  With  seven  full-page  plates  in  colors 
and  thirty-six  wood  engravings  in  the  text.  Third  revised  edition,  8vo, 
330  pages,  muslin   ^2.50  net. 

Fox,  George  Henry,  A.M.,  M.D., 

Prof  essor  of  Diseases  of  the  SMn  in  the  College  of  Physicians  and  Surgeons,  Columbia  University 
New  York,  etc.,  etc. 

SKIN  DISEASES  OF  CHILDREN.  The  work  is  based  upon  a  series 
of  papers  originally  contributed  to  the  American  Journal  of  Obstetrics, 
in  1896,  and  has  been  elaborated  and  a  large  formulary  added.  8vo, 
profusely  illustrated  by  photogravure  plates,  chromo-lithographic  plates, 
and  half-tone  cuts.     Muslin,  S2.50  net. 


8  PUBLICATIONS   OF   WILLIAM   WOOD    &   COMPANY. 

Freyer,  P.  J.,  M.A.,  M.D.,  M.Ch., 

Surgeon  to  St.  Peter's  Hospital  ;  Lieiit.-Colocial  Indian  Medical  Service  (Ret'd). 

THE  MODERN  TREATMENT  OF  STONE  IN  THE  BLADDER 
BY  LITHOLAPAXY.  A  description  of  the  operation  and  instruments, 
with  cases  illustrative  of  the  difficulties  and  complications  met  with. 
Second  edition.     One  8vo  volume,  illustrated.     Muslin,  $1.25   net. 

CLINICAL  LECTURES  ON  STRICTURE  OF  THE  URETHRA 
AND  ENLARGEMENT  OF  THE  PROSTATE.  Octavo,  115 
pages,  illustrated.      Muslin,  $1.50  net. 

Gait,  Hugh,  M.B.,  CM.,  D.P.H., 

Fellow  of  the  Faculty  of  Physicians  and  Surgeons  of  Glasgow ;   Lecturer  on  Hygiene  to  Glasgow 
Royal  Infirmary  ;'  Research  Student  and  Fellow  Glasgow  University,  etc.,  etc. 

THE  MICROSCOPY  OF  THE  MORE  COMMONLY  OCCURRING 
STARCHES.  i2mo,  112  pages,  with  22  original  micro-photographic 
plates,  illustrating  starches  from  various  grains.     Muslin,  $1.25  net. 

Qarrigues,  Henry  Jacques,  A.M.,  M.D., 

Obstetric  Surgeon  to  the  Maternity  Hospital ;  Physician  to  the  Gynecological  Department  of  the 
German  Dispensary ;  Fellow  of  the  American  Gynecological  Society  ;  Fellow  of  the  New  York 
Obstetrical  Society,  etc. 

DIAGNOSIS  OF  OVARIAN  CYSTS  BY  MEANS  OF  THE  EX- 
AMINATION OF  THEIR  CONTENTS.  8vo,  112  pages,  illus- 
trated, muslin,  $1.00  net. 

Gemmell,  Q.  H.,  F.I.C.,  F.C.S.  Ed. 

CHEMICAL  NOTES  AND  EQUATIONS,  INORGANIC  AND  OR-' 
GANIC.     One  volume  of  254  pages,  i2mo.     Muslin,  $1.75  ^^/. 

Gillespie,A.Lockhart(Edinburgh),M.D.,F.R.C.P.,(Ed.) 

MANUAL  OF  MODERN  GASTRIC  METHODS,  CHEMICAL, 
PHYSICAL  AND  THERAPEUTICAL.  One  volume,  illustrated, 
small  octavo,  muslin,  price  $1.50  net. 

Gowers,  W.  R.,  M.D., 

Assistant  Professor  of  Clinical  Medicine  in  University  College;  Senior  Assistant  Physician  to 
University  College  Hospital ;  Physician  to  the  National  Hospital  for  the  Paralj'zed  and  Epileptic. 

EPILEPSY  AND  OTHER  CHRONIC  CONVULSIVE  DISEASES. 
Their  Causes,  Symptoms,  and  Treatment.  8vo,  366  pages,  musUn, 
$1.00  net. 

DIAGNOSIS  OF  THE  DISEASES  OF  THE  BRAIN  AND  SPINAL 
CORD.     8vo,  301  pages,  muslin,  $1.00  net. 

Qrandin,  Egbert  H.,  M.D., 

Chairman  Section  on  Obstetrics  and  Gynecology,  New  York  Academy  of  Medicine;  Obstetric 
Surgeon,  New  York  Maternity  Hospital ;  Obstetrician,  New  York  Infant  Asylum,  etc. ;  and 

Gunning,  Josephus  H.,  M.D., 

Instructor  in  Electro-Therapeutics,  New  York  Post-Graduate  Medical  School  and  Hospital; 
Gynecologist  to  Riverview  Rest  for  Women  ;  Electro-Gynecologist,  Northeastern  Dispensary,  eta 

PRACTICAL  TREATISE  ON  ELECTRICITY  IN  GYNECOLOGY. 
Illustrated.     8vo,  muslin,  180  pages,  $1.75  net. 


PUBLICATIONS   OF   WILLIAM   WOOD   &   COMPANY.  9 

Qriinwald,  Dr.  Ludwig,  of  Munich. 

A  TREATISE  ON  NASAL  SUPPURATION  ;  OR,  SUPPURATIVE 
DISEASES  OF  THE  NOSE  AND  ITS  ACCESSORY  SINUSES. 
Translated  from  the  Second  German  Edition  by  Wm.  Lamb,  M.D., 
M.C.,  M.R.C.P.  (of  Birmingham).  One  volume  of  347  pages,  octavo, 
illustrated  by  engravings,  plates,  and  a  table.     Extra  muslin,  $3.00  net. 

Haab,  Prof.  O.,  M.D.,  and  Clarke,  Ernest,  M.D. 

AN  ATLAS  ON  OPHTHALMOSCOPY.  One  i2mo  volume,  containing 
64  full-page  plates,  102  figures,  superbly  executed  by  chromo- lithography, 
with  complete  descriptive  text  and  an  introductory  chapter.  Muslin. 
Price  $1.50  tiet.     (  Wood's  Medical  Hand  Atlases.) 

Hamilton,  Frank  Hastings,  A.M.,  M.D.,  LL.D., 

Professor  of  the  Practice  of  Surgery,  with  Operations,  and  of  Clinical  Surgery,  in  BeUevue  Hospital 
Medical  College ;  Visiting  Surgeon  to  BeUevue  Hospital ;  Consulting  Surgeon  to  Bureau  of 
Surgical  and  Medical  Relief  for  the  Out-Door  Poor,  at  Bellevua  Hospital;  to  the  Central 
Dispensary ;  and  to  the  Hospital  for  the  Ruptured  and  Crippled ;  Fellow  of  the  New  York 
Academy  of  Medicine,  etc. 

THE  PRINCIPLES  AND  PRACTICE  OF  SURGERY.  Illustrated 
with  four  hundred  and  sixty-seven  engravings  on  wood.  Royal  8vo, 
954  pages.  '  In  muslin,  $4.00  net. 

Heitzmann,  Louis,  M.D.  (New  York). 

URINARY  ANALYSIS  AND  DIAGNOSIS  by  Microscopical  and 
Chemical  Examination.  One  volume  of  271  pages,  octavo,  illustrated  by 
108  original  wood-engravings,  28  of  which  are  full-page  in  size,  from 
drawings  by  the  author  from  actual  specimens.    Extra  muslin,  $2.00  net. 

Helferich,  H.,  M.D., 

Professor  at  the  University  of  Greifswald. 

AN  ATLAS  OF  FRACTURES  AND  DISLOCATIONS.  Translated 
from  the  Third  Revised  German  Edition  by  Jonathan  Hutchinson, 
Jr.,  F.R.  C.S.,  London.  This  volume  deals  with  fractures  and  disloca- 
tions in  all  their  details  and  is  beautifully  illustrated  by  68  superb  full- 
page  colored  plates.  130  pages  of  text,  containing  126  illustrations. 
8vo  (5^x8^  inches).  Muslin,  uniform  with  other  volumes  of  the 
series,  $3.00  net.     (Wood's  Medical  Hand  Atlases.  J 

Herman,  Q.  Ernest,  fl.B.  Lond.,  F.R.C.P., 

Obstetric  Physician  to  and  Lecturer  on  Midwifery  at  the  London  Hospital  ;  Consulting  Physician- 
Accoucheur  to  the  Tower  Hamlets  Dispensary  ;  Examiner  in  Midwifery  to  the  Universities  of 
London  and  Oxford  ;  Late  President  of  the  Obstetrical  Society  of  London  and  of  the  Hunterian 
Society  ;  Formerly  Physician  to  the  General  Lying-in  Hospital  and  to  the  Eastern  District  of  the 
Royal  Maternity  Charity,  and  Examiner  in  Midwifery  to  the  Royal  College  of  Surgeons. 

DISEASES  OF  WOMEN;  A  CLINICAL  GUIDE  TO  THEIR 
DIAGNOSIS  AND  TREATMENT.  Octavo,  886  pages,  profusely 
illustrated.     Extra  muslin,  $5.00  net  j  leather,  $5.75  net. 

DIFFICULT  LABOR  :  A  Guide  to  its  Management  for  Students  and 
Practitioners.  460  pages,  demi-octavo,  including  complete  index,  mus- 
lin, $2.00  net. 


lo  PUBLICATIONS   OF   WILLIAM   WOOD   &   COMPANY. 

Herrick,  Clinton  B.,  M.D.,  Troy,  N.  Y. 

Lecturer  in  Clinical  Surgery,  Albanj-  Medical  College  ;  Surgeon  to  the  Delaware  and  Hudson,  and 
the  Fitchburg  Railways;  President  of  the  New  York  State  Association  of  Railway  Surgeons, 
etc.,  etc. 

RAILWAY  SURGERY.  A  handbook  on  the  management  of  injuries. 
The  only  book  on  the  subject.  One  volume,  octavo,  profusely  illustrated 
by  numerous  line  and  half-tone  engravings.     Muslin,  $2.00  net. 

Holden,  Luther,  fl.D., 

Ex-President  and  Member  of  the  Court  of  Examiners  of  the  Royal  College  of  Surgeons  of  England  ; 
Consulting  Surgeon  to  Saint  Bartholomew's  and  the  Foundling  Hospitals  ;  assisted  by 

Shuter,  James,  F.R.C.S.,  fl.A.,  fl.B.  Cantab., 

Assistant  Surgeon  to  the  Royal  Free  Hospital ;  late  Demonstrator  of  Physiology,  and  Assistant 
Demonstrator  of  Anatomy,  at  Saint  Bartholomew's  Hospital. 

HUMAN  OSTEOLOGY.  Comprising  a  Description  of  the  Bones,  with 
Delineations  of  the  Attachments  of  the  Muscles,  the  General  and  Micro- 
scopic Structure  of  Bone  and  its  Development.  Sixth  edition.  With 
sixty-six  full-page  lithographic  plates,  and  eighty-nine  wood-engravings. 
8vo,  285  pages,  muslin,  $1.00  net. 

Household  Practice. 

See  WOOD'S  HOUSEHOLD  PRACTICE. 


Hudson,  E.  D.,  Jr.,  A.m.,  fl.D., 

E*rof  essor  of  General  Medicine  and  Diseases  of  the  Chest  in  the  New  York  Polyclinic  ;  Physician  to 
Bellevue  Hospital,  etc. 

A  MANUAL  OF  THE  PHYSICAL  DIAGNOSIS  OF  THORACIC 
DISEASES.    Svo,  162  pages,  profusely  illustrated.    Muslin,  $1.25  net. 

Hutchinson,  Jonathan,  F.R.S. 

THE  PEDIGREE  OF  DISEASE.  Being  Six  Lectures  on  Tempera- 
ment, Idiosyncrasy,  and  Diathesis.     Muslin,  $1.00  net. 

Hutchinson,  Robert,  M.D.,  Edin.,  M.R.C.P., 

Assistant  Physician  to  the  London  Hospital  and  to  the  Hospital  for  Sick  Children. 

FOOD  AND  THE  PRINCIPLES  OF  DIETETICS.  Octavo,  566 
pages,  illustrated  by  three  colored  plates  and  many  wood  engravings. 
Muslin,  $5.00  net. 

Ingals,  E.  Fletcher,  A.M.,  M.D.,  Chicago, 

Professor  of  Diseases  of  the  Chest,  Throat  and  Nose,  Rush  Medical  College ;  Professor  of  Laryn- 
gology and  Rhioology,  Chicago  Polyclinic  ;  Laryngologist  to  the  St.  John's  Hospital  and  the 
Presbyterian  Hospital,  Chicago,  etc.,  etc. 

DISEASES  OF  THE  CHEST,  THROAT  AND  NASAL  CAVITIES. 
Including  Physical  Diagnosis  and  Diseases  of  the  Lungs,  Mediastinum, 
Heart,  and  Aorta,  Laryngology  and  Diseases  of  the  Larynx,  Pharynx, 
and  Nose,  and  Special  Diseases  of  the  Thyroid  Gland  and  CEsophagus. 
Fourth  edition.  Large  octavo,  787  pages,  illustrated  by  254  cuts  and 
a  plate  in   colors.     Extra  muslin,  $4.50  net  j  sheep,  $5.25  net. 


PUBLICATIONS   OF   WILLIAM   WOOD   &  COMPANY.  ii 

Jakob,  Dr.  Christfried. 

AN  ATLAS  OF  THE  NERVOUS  SYSTEMS,  NORMAL  AND 
PATHOLOGICAL,  together  with  a  Sketch  of  the  Anatomy,  Pathology, 
and  Therapy  of  the  same.  Translated  and  edited  (authorized)  by 
Joseph  Collins,  M.D.  One  T2mo  volume,  78  plates,  with  complete 
descriptive  text.  Muslin.  Price,  $1.50  net.  (Wood's  Medical  Hand 
Atlases.) 

Johnston,  James  C,  A.B.,  M.D., 

Chief  of  Clinic,  Department  of  Dermatology,  Cornell  University  Medical  College  ;  Physician  Skin 
and  Venereal  Diseases,  Presbyterian  Hospital ;  formerly  Instructor  in  Dermatology,  New  York 
Polyclinic  and  Post^Graduate  Medical  School. 

ATLAS  OF  SKIN  AND  VENEREAL  DISEASES.  New  edition, 
with  some  new  plates,  and  text  entirely  rewritten.  Half-morocco  bind- 
ing.    Price,  $2^5.00.     (Sold  by  subscription  only.) 

Kaposi,  Dr.  floriz. 

Professor  of  Dermatology  and  Syphilis,  and  Chief  of  the  Clinic  and  Division  for  Skin  Diseases  in  the 
Vienna  University. 

PATHOLOGY  AND  TREATMENT  OF  DISEASES  OF  THE 
SKIN.  For  Practitioners  and  Students.  Translation  of  the  latest  Ger- 
man edition.  8vo,  684  pages,  84  illustrations,  and  a  colored  plate,  mus- 
lin, $4.00  net;  leather,  $4.75  net. 

Kellogg,  Theodore  H.,  A.M.,  fl.D., 

New  York,  Late  Superintendent,  Willard  State  Hospital ;  former  Physician- in-Chief  of  the  New  YorX 
City  Asylum  for  the  Insane,  etc.,  etc. 

A  TEXT-BOOK  ON  MENTAL  DISEASES,  for  the  Use  of  Students 
and  Practitioners  of  Medicine.  One  large  octavo  volume,  of  792  pages, 
illustrated  by  engravings  and  charts.     Muslin,  $5.00  net. 


Keyes,  Edward  L.,  A.M.,  M.D., 

and 

Chetwood,  Charles   H.,   M.D. 

VENEREAL  DISEASES,  THEIR  COMPLICATIONS  AND  SE- 
QUELS. Octavo,  364  pages,  profusely  illustrated  by  eight  full-page 
plates  in  black  and  colors,  and  by  107  wood- engravings  in  the  text. 
Muslin,  price,  $2.75  net. 

Kirchhoff,  Dr.  Theodore, 

Physician  to  the  Schleswig  Insane  Asylum  and  Privat-Docent  at  the  University  of  Kiel. 

HANDBOOK  OF  INSANITY  FOR  PRACTITIONERS  AND  STU- 
DENTS. Illustrated  with  eleven  plates.  8vo,  362  pages.  Muslin, 
$2.25  net ;  flexible  leather,  gilt  top,  $2.75  net. 

Knies,  Max,  M.D., 

Professor  Extraordinary  at  the  University  of  Freiburg. 

THE  EYE  AND  ITS  DISEASES,  IN  RELATION  TO  THE  DIS- 
EASES OF  OTHER  ORGANS.  Translated  and  edited  by  H.  D. 
NoYES,  M.D.     8vo,  470  pages,  illustrated,  muslin,  $3.50  7iet. 


12  PUBLICATIONS   OF   WILLIAM   WOOD   &   COMPANY. 


Kirkes'  Handbook  of  Physiology. 

HANDBOOK  OF  PHYSIOLOGY.  By  W.  Morrant  Baker,  F.R.C.S., 
and  Vincent  Dormer  Harris,  M.D.  Lond.  F.R. C.P.  Sixteenth 
American  Edition. 

Tlioroughly  revised  by  Warren  Coleman,  M.D.,  late  Professor  of 
Physiology  in  the  Woman's  Medical  College,  New  York;  Instructor  in 
Materia  Medica  and  Therapeutics  and  in  Clinical  Medicine,  Cornell 
Medical  College,  New  York;  Physician  to  the  City  Hospital,  New 
York,  etc.,  etc.,  and  Charles  L.  Dana,  A.M.,  M.D.,  Professor  of 
Nervous  and  Mental  Diseases  in  the  New  York  Post-Graduate  Medical 
School,  and  in  Dartmouth  Medical  College ;  Visiting  Physician  to 
Bellevue  Hospital ;  Neurologist  to  the  Montefiore  Home  ;  ex-Presi- 
dent of  the  American  Neurological  Association,  etc. 

One  volume,  8vo,  illustrated  with  a  colored  plate  and  five  hundred  and 
sixteen  illustrations,  in  black  and  numerous  colors',  muslin,  $3.00  net ; 
leather,  $3.75  net. 

Landau,  Prof.  Dr.  Leopold,  and 

Landau,  Dr.  Theodor, 

Berlin. 

THE  HISTORY  AND  TECHNIQUE  OF  THE  VAGINAL  RADI- 
CAL OPERATION.  Translated  by  B.  L.  Eastman,  M.  D.  ,  Berlin,  and 
Arthur  E.Giles,  M.D.,  London.  One  volume,  octavo,  with  numer- 
ous original  illustrations.     Muslin,  $2.00  net. 

Leftwitch,  Ralph  Winnington,  M.D., 

Late  Assistant  Physician  to  the  East  London  Children's  Hospital. 

AN  INDEX  OF  SYMPTOMS  AS  A  CLUE  TO  DIAGNOSIS. 
Second  Edition.     i2mo,  282  pages,  with  frontispiece.     Muslin,  $2.00  net. 

Lehmann,  Prof.  K.  B.,  and 

Neumann,  Rudolf. 

ATLAS  AND  ESSENTIALS  OF  BACTERIOLOGY.  Sixty  three 
superb  plates,  description  facing  each,  and  150  pages  of  text.  Muslin. 
Price,  $  1 .50  net.     (  Wood's  Medical  Hand  Atlases  ) 

Ling,  P.  He. 

SYSTEM  OF  MANUAL  TREATMENT  AS  APPLICABLE  TO 
SURGERY  AND  MEDICINE.  By  Arvid  Kellgren,  M.D.  Edin. 
Svo,  151  pages,  with  79  illustrations,  muslin,  |i.oo  net. 

Liveing,  Robert,  A.M.  and  M.D.  Cantab.,  F.R.C.P.  Lond. 

Lecturer  on  Dermatology  to  the  Middlesex  Hospital  Medical  School ;  lately  Physician  to  thn 
Middlesex  Hospital;  Author  of  "Notes  on  the  Treatment  of  Skin  Diseases,"  "Elephantiasis 
Graecorum,"  etc. 

A  HANDBOOK  ON  THE  DIAGNOSIS  OF  SKIN  DISEASES. 
One  volume,  i6mo,  266  pages,  muslin,  $1.00  net. 

NOTES  ON  THE  TREATMENT  OF  SKIN  DISEASES.  One 
volume,  T6mo,  127  pages,  muslin,  75c.  net. 


t 


PUBLICATIONS   OF    WILLIAM    WOOD   &   COMPANY.  13 

Loomis,  Alfred  L.,  M.D.,  LL.D., 

Professor  of  Pathology  and  Practical  Medicine,  in  the  Medical  Department  of  the  Univei-sity  of  the 
City  of  New  York  ;  Visiting  Physician  to  Bellevue  Hospital,  etc. 

A  TEXT-BOOK  OF  PRACTICAL  MEDICINE.  One  handsome  8vo 
volume  of  1,147  pages,  illustrated  by  two  hundred  and  eleven  engravings. 
Eleventh  edition.     Muslin,  $5.00  net ;  leather,  $5.75  fiet. 

LESSONS  IN  PHYSICAL  DIAGNOSIS.  Eleventh  revised  edition. 
Revised  by  Alexander  Lambert,  M.D.,  New  York.  One  volume, 
353  pages,  8vo,  illustrated  by  numerous  engravings  in  black  and  colors, 
muslin,  $2.50  net. 

Luff,  Arthur  P.,  M.D.,  B.Sc,  F.R.C.P.  Lond. 

GOUT;  ITS  PATHOLOGY  AND  TREATMENT.  One  volume,  256 
pages.     Muslin,  $1.75  net. 

Macfarlane,  A.  W.,  M.D., 

Fellow  of  the  Royal  College  of  Physicians,  Edinburgh  ;  Fellow  of  the  Royal  Medical  and  Chirurgical 
Society  of  London  ;  Examiner  in  Medical  Jurisprudence  in  the  University  of  Glasgow,  etc. 

INSOMNIA  AND  ITS  THERAPEUTICS.  8vo,  302  pages,  muslin, 
$1.50  net. 

Macnaughton=Jones,  H.,  M.D.,  fl.CH.  London. 

Master  of  Obstetrics,  Royal  University  of  Ireland ,  etc. 

PRACTICAL  MANUAL  OF  DISEASES  OF  WOMEN  AND  UTE- 
RINE THERAPEUTICS.  For  Students  and  Practitioners.  Eighth 
Edition,  Revised  and  Enlarged.  One  volume  of  977  pages,  octavo,  most 
profusely  illustrated  by  28  plates  and  640  engravings  in  the  text.  Extra 
muslin,  $5.00  net. 

POINTS  OF  PRACTICAL  INTEREST  IN  GYNECOLOGY.  (New 
Edition  in  Press.) 

Mauthner,  Ludwig, 

Royal  Professor  of  the  University  of  Vienna. 

THE  SYMPATHETIC  DISEASES  OF  THE  EYE.  Translated 
from  the  German  by  Warren  Webster,  M.D.,  James  A.  Spaulding, 
M.D.      i2mo,  220  pages,  muslin,  $1.50  net. 

May,  Charles  H.,  M.D., 

Chief  of  Clinic  and  Instructor  in  Ophthalmology,  Eye  Department,  College  of  Physicians  and  Sur- 
geons, Medical  Department,  Columbia  University,  New  York  ;  and 

Mason,  Charles  F.,  M.D., 

Late  Assistant  Surgeon,  U.S.A. 

AN  INDEX  OF  MATERIA  MEDICA.  With  Prescription  Writing, 
including  Practical  Exercises.  32mo,  muslin,  $1.00  net.  (Wood's 
Pocket  Ma?iuals.) 


14  PUBLICATIONS   OF   WILLIAM    WOOD   &   COMPANY. 

May,  Charles  H.,  M.D. 

MANUAL  OF  THE  DISEASES  OF  THE  EYE.  Second  Edition. 
i2mo,  416  pages,  with  275  original  illustrations  and  22  colored  figures 
on  13  full-page  plates.     Bound  in  muslin.     Price,  $2.00  net. 

McGillicuddy,  T.  J.,  A.fl.,  fl.D. 

FUNCTIONAL  DISORDERS  OF  THE  NERVOUS  SYSTEM  IN 
WOMEN.  8vo,  373  pages,  illustrated  by  forty-five  wood-engravings 
and  two  chromo-lithographic  plates.  Extra  muslin,  $2.75  net  j  flexible 
leather,  $3.25  net. 

McKay,  W.  J.  Stewart,  M.C.,M.Ch.,  B.Sc.  Lond. 

Senior  Surgeon  to  the  Lewisham  Hospital  for  Women  and  Children,  Sydney  ;  Late  Surgeon  to  the 
Benevolent  Asylum  Maternity  Hospital,  Sydney,  etc. 

LAWSON  TAIT'S  PERINEAL  OPERATIONS  and  an  ESSAY  ON 
CURETTAGE  OF  THE  UTERUS.  One  volume,  8vo,  illustrated. 
Muslin,  $1.00  net. 

THE  HISTORY  OF  ANCIENT  GYNECOLOGY.  Octavo,  322  pages. 
Muslin,  $3.00  net. 

Medical   Record. 

A  WEEKLY  JOURNAL  OF  MEDICINE  AND  SURGERY.  Sub- 
scription price,  $5.00  per  year. 

Medical  Record  Visiting  List. 

See  VISITING  LIST. 

Miller. 

STUDENTS'  HISTOLOGY.  A  course  of  normal  histology  for  students 
and  practitioners  of  Medicine. 

Re-written  and  enlarged  by 

Herbert  U.  Williams,  M.D., 

Professor  of  Pathology  and  Bacteriology,  University  of  Buffalo. 

One  volume  of  273  pages,  octavo,  profusely  illustrated.  Extra  muslin, 
$2.00  net. 

Montenegro,   Dr.  Jose  Verdes, 

Ex-Interne  of  the  Central  University  of  Medicine;  Associate  Physician  of  the  Hospital  de  la  Princesa, 
and  Professor  at  the  Municipal  Blicrographical  Laboratory,  Madrid. 

BUBONIC  PLAGUE.  Its  Course  and  Symptoms  and  Means  of  Preven- 
tion and  Treatment,  according  to  the  Latest  Scientific  Discoveries  ; 
including  Notes  on  Cases  in  Oporto.  With  an  Appendix  by  the  Author. 
Authorized  Translation  by  W.  Munro,  M.D.  Octavo,  84  pages. 
Muslin.      Price,  $1.50  net. 

Moore,  John  William. 

A  TEXT-BOOK  OF  THE  ERUPTIVE  AND  CONTINUED 
FEVERS.  8vo,  535  pages,  illustrated  with  lithographic  plates  and 
temperature  charts,  muslin,  $3.25  net. 


PUBLICATIONS   OF   WILLIAM   WOOD    &   COMPANY.  15, 

Morris,  Henry,  M.A.,  M.B.  Lond.,  F.R.C.S., 

Surgeon  to  and  Lecturer  on  Surgery  at  the  Middlesex  Hospital. 

INJURIES  AND  DISEASES  OF  THE  GENITAL  AND  URINARY 
ORGANS.  One  volume  of  494  pages,  8vo,  illustrated  by  96  wood  en- 
gravings, muslin,  $3.25  tiet. 

Morrow,  P.  A.,  A.M.,  M.D., 

Clinical  Professor  of  Venereal  Diseases  ;  Consulting  Surgeon  to  the  Bellevue  Out-Door  Depart- 
ment, etc. 

VENEREAL  MEMORANDA.  A  Manual  for  the  Student  and  Prac- 
titioner. Second  edition.  32mo,  muslin,  $1.00  net.  (Wood's  Pocket' 
Manuals.) 

DRUG  ERUPTIONS.  A  Clinical  Study  of  the  Irritant  Effect  of  Drugs  up- 
on  the  Skin.     8vo,  206  pages,  one  lithographed  plate,  muslin,  $1.50  net. 

MoulHn,  C.  W.  Mansell, 

SPRAINS,  THEIR  CONSEQUENCES  AND  TREATMENT.  8vo^ 
221  pages,  muslin,  $1.25  net. 

Munson,  Edward  L.,  A.M.,  M.D., 

Captain,  Medical  Department,  United  States  Army. 

THE  THEORY  AND  PRACTICE  OF  MILITARY  HYGIENE.  One 
royal  octavo  volume  of  983  pages,  profusely  illustrated  by  nearly  400 
engravings  and  by  eight  full-page  plates.  Muslin,  $8.00  net ;  Leather, 
$8.75  net.     Adopted  as  standard  for  the  United  States  Army. 

Murrell,  William,  M.D.,  F.R.C.P.  Lond. 

A  MANUAL  OF  MATERIA  MEDICA  AND  THERAPEUTICS. 
Revised  to  Conform  with  American  Practice  by  Frederick  A.  Castle,. 
M.D.,  New  York.  One  volume  of  522  pages,  8vo,  with  complete  index. 
Muslin,  $3.00  net. 

Nichols,  J.  B.,  M.D.,  Washington,  D.  C. 

CLINICAL  LABORATORY  METHODS.  A  concise  guide  to  Clinical 
Diagnosis  of  Disease.     One  volume,  8vo.     In  Press. 

Noyes,  Henry  D.,  fl.D., 

Professor  of  Ophthalmology  and  Otology  in  Bellevue  Hospital  Medical  College  ;  Executive  Surgeon 
to  the  New  York  Eye  and  Ear  Infirmary  ;  recently  President  of  the  American  Ophthalmologieal 
Society,  etc. 

A  TEXT-BOOK  ON  DISEASES  OF  THE  EYE.  Royal  8vo,  832 
pages,  richly  illustrated  with  chromo-lithographic  plates  and  269 
engravings.     Second  edition.     Muslin,  $5.00  net ;  sheep,  $5.75  net. 

Paget,  Stephen,  F.R.C.S.  Lond. 

.ESSAYS  FOR  STUDENTS.  One  volume  of  180  pages,  8vo,  muslin,. 
$1.00  net. 

EXPERIMENTS  ON  ANIMALS.  With  an  Introduction  by  Lord  Lis- 
ter.    One  volume,  of  286  pages,  i2mo.     Extra  muslin,  $2.50  net. 


l6  PUBLICATIONS   OF   WILLIAM   WOOD   &   COMPANY. 


Parkes,  E.,  fl.D. 

A  MANUAL  OF  PRACTICAL  HYGIENE.  Edited  by  F.  S.  B. 
Francois  de  Chaumont,  M.D.  Sixth  edition.  With  an  Appendix, 
giving  the  American  practice  in  matters  relating  to  hygiene.  Pre- 
pared by  and  under  the  supervision  of  Frederick  N.  Owen,  Civil  and 
Sanitary  Engineer.  Two  volumes  in  one,  8vo,  946  pages.  Illustrated 
with  nine  full-page  plates  and  fine  wood-engravings,  muslin,  $4.00  net. 

Partridge,  Edward  L.,  fl.D., 

New  York  City. 

THE  OBSTETRICAL  REMEMBRANCER.  Profusely  illustrated 
with  miniature  wood-engravings.  (Wood's  Pocket  Manuals.)  32mo, 
muslin,  $1.00  net. 

Pictures  for  Physicians'  Offices  and  Libraries. 


Edward  Jenner,  the  first  Inocula- 
tion of  Vaccine,  May  14,  1796. 

Andrew  Vesalius,  the  Anatomist. 

Spoonful  Every  Hour. 

The  Sick  Wife. 

Ambrose  Pare  Demonstrating  the 
Use  of  Ligatures. 

The  Young  Mother. 

The  Village  Doctor. 


Prof.  Charcot's  Clinic  at  the  "  Salp^- 
triere  "  Hospital,  Before  the  Oper- 
ation. 

The  Rebellious  Patient. 

Study  in  Anatomy. 

William  Harvey  Demonstrating  the 
Circulation  of  the  Blood. 

The  Anatomical  Lecture. 

The  Accident. 

The  Doctor. 

Anaesthesia. 

Size  of  each,  19x24  inches.  Price,  each,  $1.00  «.?/.  Illustrated  catalogue 
sent  upon  application. 

Prof.  Billroth's  Clinic,  Vienna,  size  24x32,  $2.00  net. 

Piffard,  Henry  Q.,  A.fl.,  fl.D., 

Professor  of  Dermatology,  University  of  the  City  of  New  York  ;  Surgeon  to  the  Charity  Hospital, 
etc. 

A  GUIDE  TO  URINARY  ANALYSIS  FOR  THE  USE  OF  PHY- 
SICIANS AND  STUDENTS.     8vo,  88  pages,  illustrated,  $1.00  net. 

Piicher,  L.  5.,  M.D. 

THE  TREATMENT  OF  WOUNDS.  Its  Principles  and  Practice, 
General  and  Special.     One  volume,  8vo,  465  pages,  profusely  illustrated. 

Muslin,  $3.00  net. 

Porter,  William  Henry,  fl.D., 

Late  Professor  of  Clinical  Medicine  and  Pathology  in  the  New  York  Post-Graduate  Medical  School 
and  Hospital ;  Curator  to  the  Presbyterian  Hospital. 

A  PRACTICAL  TREATISE  ON  RENAL  DISEASES  AND  URI- 
NARY ANALYSIS.  360  pages,  one  hundred  illustrations,  muslin, 
$2.50  net. 


PUBLICATIONS   OF   WILLIAM   WOOD  &   COMPANY.  17 

Pozzi,  S.,  M.D., 

Professeur  Agr6g6  k  la  Facultfi  de  MSdecine,  Chirurgien  de  I'Hopital  Lourcine-Pascal,  Paris. 

TREATISE  ON  MEDICAL  AND  SURGICAL  GYN^XOLOGY. 
Translated  from  the  third  French  edition,  under  the  supervision  of 
Brooks  H.  Wells,  M.  D.,  Lecturer  on  Gynaecology  at  the  New  York 
Polyclinic.  One  royal  Svo  volume  of  about  936  pages,  illustrated  by  600 
fine   wood-engravings.     Muslin,  $5.50  ;/^/y   leather,  $6.25  «<?/.     • 

Rabagliati,  A.,  M.A.,  M.D.,  F.R.C.S.  Ed. 

Honorary  Gynecologist,  Late  Senior  Honorary  Surgeon,  Bradford  Royal  Infirmary. 

AIR,  FOOD,  AND  EXERCISE.  AN  ESSAY  ON  THE  PREDIS- 
POSING CAUSES  OF  DISEASE.  Second  edition.  Small  Svo, 
236  pages,  $2.00  net. 

APHORISMS,  DEFINITIONS,  REFLECTIONS,  AND  PARADOX- 
ES, Medical,  Surgical,  and  Dietetic.  One  volume  of  305  pages, 
Svo.     Muslin,  $2.50  net. 

ON  SOME  SYMPTOMS  WHICH  SIMULATE  DISEASE  OF 
THE  PELVIC  ORGANS  IN  WOMEN,  and  their  treatment  by 
massage.     Svo,  illustrated  by  photogravure  plates.     Muslin,  $1.50  net. 

Reference  Handbook  of  the  Medical  Sciences. 

Revised  Edition. 
By  various  authors.  Edited  by  Albert  H.  Buck,  M.D.,  Clinical  Pro- 
fessor of  the  Diseases  of  the  Ear,  in  the  College  of  Physicians  and  Sur- 
geons, New  York;  Consulting  Aural  Surgeon,  New  York  Eye  and  Ear 
Infirmary.  Eight  volumes,  imperial  Svo,  muslin,  $7.00  per  volume; 
leather,  $S.oo  per  volume;  half-morocco,  $9.00  per  volume.  (Subscrip- 
tion.)    Circular  on  application. 

Reynolds,  Edward, 

Fellow  of  the  American  Gynecological  Society;  of  the  Obstetric  Society  of  Boston,  etc..  Assistant 
in  Obstetrics  m  Harvard  University;  Physician  to  Out-Patients  of  the  Boston  Lying-in  Hos- 
pital, etc. 

PRACTICAL  MIDWIFERY.  A  Handbook  of  Treatment.  Third 
revised  edition.  Svo,  427  pages,  small  octavo,  121  illustrations.  Mus- 
lin, $2.25  net. 

Ringer,  Sidney,  fl.D.,  F.R.S., 

Professor  of  Clinical  Medicine  Holme  University  College  ;  Physician  to  University  College  Hospital ; 
and 

Sainsbury,  Harrington,  fl.D.,  F.R.C.P., 

Physician  to  the  Royal  Free  Hospital,  etc.,  etc. 

A  HANDBOOK  OF  THERAPEUTICS.  Thirteenth  edition.  Svo, 
757  P^ges,  muslin,  $4.00  Tiet. 

Robson,  A.  W.  Mayo,  F.R.C.S.,  Leeds,  England. 

DISEASES  OF  THE  GALL-BLADDER  AND  BILE-DUCTS,  IN- 
CLUDING GALL-STONES.  Second  Edition.  One  volume  of  313 
pages,  octavo,  profusely  illustrated.     Extra  muslin,  $3.00  net. 

SURGERY  OF  THE  STOMACH.     (In  Press.) 


i8  PUBLICATIONS   OF   WILLIAM   WOOD   &   COMPANY. 


Rockwell,  A.  D.,  A.M.,  M.D. 

THE  MEDICAL  AND  SURGICAL  USES  OF  ELECTRICITY. 
Entirely  rewritten  fiom  the  former  book  by  Beard  and  Rockwell.  One 
large  8vo  volume  of  628  pages,  profusely  illustrated.  Muslin,  $3.75 
«(f/y  sheep,  $4.50  net 

Rose,  William,  M.B.,  B.S.  Lond.,  F.R.C.S.,  and 
Carless,  Albert,  M.S.  Lond.,  F.R.C.S. 

A  MANUAL  OF  SURGERY  FOR  STUDENTS  AND  PRACTI- 
TIONERS. Second  Revised  and  Enlarged  Edition.  One  volume, 
I  190  pages,  profusely  illustrated.  Octavo,  muslin,  $5.00  nef ;  leather, 
$5-75  "^^-     The  smallest  complete  surgery  published. 

Roosa,  D.  B.  St.  John,  fl.D.,  and  Ely,  Edward  T.,  fl.D. 

OPHTHALMIC  AND  OTIC  MEMORANDA,  f  Wooa's  Pocket  Man- 
uals.)   Fourth  edition.    One  volume,  32mo,  298  pages,  muslin,  ^i.oo  net. 

Roosa,  D.  B.  St.  John,  fl.D., 

Professor  of  Diseases  of  the  Eye  and  Ear  in  the  University  of  the  City  of  New  York  ;  etc. ,  etc. 

TEXT-BOOK  ON  DISEASES  OF  THE  EYE.  Including  a  sketch 
of  its  anatomy.  Illustrated  by  178  engravings  and  2  chromo-litho- 
graphic  plates.     Leather,  $5.25  net. 

A  VEST-POCKET  MEDICAL  LEXICON.  Being  a  Dictionary  of  the 
Words,  Terms,  and  Symbols  of  Medical  Science.  With  an  Appendix. 
Third  revised  and  enlarged  edition.  One  volume,  64mo,  roan,  75c.  net; 
or  tucks,  $1.00  net. 

THE  OLD  HOSPITAL,  AND  OTHER  PAPERS.     Being  the  second 

revised  and  enlarged  edition  of  "A  Doctor's  Suggestions."     8vo,  320 
pages,  gilt  top,  uncut,  dark  olive  cloth,  $3.00  net. 

Roth,  Otto. 

THE  MATERIA  MEDICA  OF  MODERN  MEDICINE.  Second 
edition.  Translated  from  the  revised  German  edition  and  adapted  to 
the  U.  S.  Pharmacopoeia.      8vo,  467  pages,  muslin,  $1.75  net. 

Sachs,  B.,  n.D., 

Professor  of  Mental  and  Nervous  Diseases  in  the  New  York  PolycUnic  ;  Consulting  Neurologist  to 
the  Mt.  SLnai  Hospital ;  Neurologist  to  the  .Monteflore  Home  for  Chronic  Invalids;  etc. 

A  TREATISE  ON  THE  NERVOUS  DISEASES  OF  CHILDREN. 
For  Physicians  and  Students.  8vo,  688  pages,  profusely  illustrated  with 
colored  plate,  muslin,  $4.25  fiet. 

Salomonsen,  C.  J.,  and  Trelease,  William. 

BACTERIOLOGICAL  TECHNOLOGY  FOR  PHYSICIANS.  Au- 
thorized translation  from  the  Second  Revised  Danish  edition.  8vo,  163 
pages,  72  illustrations,  muslin,  $1.25  net. 


PUBLICATIONS   OF    WILLIAM   WOOD   &   COMPANY.  19 

Savill,  Thomas,    D.,  M.D., 

Physician  to  the  West  End  Hospital  for  Diseases  of  the  Nervous  System,  London,  etc.,  etc. 

CLINICAL  LECTURES  ON  NEURASTHENIA.  Revised  edition. 
(In  Press.) 

Schaeffer,  Oscar,  M.D. 

ANATOMICAL  ATLAS  OF  OBSTETRIC  DIAGNOSIS  AND 
TREATMENT.  Sixty-four  beautifully  executed  full-page  chromo- 
lithographic  plates,  containing  142  figures.  Together  with  250  pages  of 
descriptive  text  and  treatise.  Muslin.  Price,  $1.50  net.  (Wood's 
Medical  Hafid  Atlases.  J 

Schmidt=Rimpler,  Dr.  Herman, 

Professor  of  Ophthalmology  and  Diseases  of  the  Ophthalmoscopic  Clinic  at  Marburg,  Germany. 

OPHTHALMOLOGY  AND  OPHTHALMOSCOPY.  A  Complete 
Treatise  upon  Diseases  and  Injuries  to  the  Eye,  for  Students  and  Prac- 
titioners of  Medicine.  Revised  and  edited  by  D.  B.  St.  John  Roosa, 
M.D.,  Professor  of  Diseases  of  the  Eye  and  Ear  in  the  New  York  Post- 
Graduate  Medical  School,  etc.  Royal  8vo,  571  pages,  illustrated  by 
183  wood-engravings  and  by  three  colored  plates.     Muslin,  $5.00  ?iet. 

Schreiber,  August. 

GENERAL  ORTHOPEDICS,  INCLUDING  ORTHOPEDIC  SUR- 
GERY. Complete  translation  from  the  original  German  edition.  Svo, 
357  pages,  388  illustrations,  muslin,  $1.75  ?iet. 

Schroeder,  Aimee  Raymond,  M.D. 

HEALTH  NOTES  FOR  YOUNG  WIVES.  lamo,  218  pages,  fancy 
half  cloth,  $1.00  net. 

Semeleder,  Dr.  Friedricii, 

Formerly  Physician  in  Ordinary  to  his  Majeiiy,  ilie  Emperor  of  Mexico,  etc.,  etc. 

RHINOSCOPY  AND  LARYNGOSCOPY:  THEIR  VALUE  IN 
PRACTICAL  MEDICINE.  Translated  from  the  German  by  Edward 
T.  Caswell.  M.D.  With  woodcuts  and  two  chromo-lithographic  plates. 
Svo,  191  pages,  muslin,  $2.50  net. 

Sexton,  Samuel,  M.D., 

Aural  Surgeon  to  the  Xew  York  Eye  and  Ear  Infirmary ;  Fellow  of  the  American  Otological 
Society  ;  Fellow  of  the  New  York  Academy  of  Medicine  ;  Member  of  the  Medical  Society  of  the 
County  of  New  York,  and  of  the  Practitioners'  Society  of  New  York. 

THE  EAR  AND  ITS  DISEASES,  BEING  PRACTICAL  CONTRI- 
BUTIONS TO  THE  STUDY  OF  OTOLOGY.  Edited  by  Christ- 
opher J.  CoLLES,  M.D.     Svo,  473  pages,  illustrated,  muslin,  $3.25  net. 

Smart,  Chas.,  M.D.,  Major  U.S.A. 

A  HANDBOOK  FOR  THE  HOSPITAL  CORPS  OF  THE  UNITED 
STATES  ARMY  AND  STATE  MILITARY  FORCES.  Third  edi- 
tion, revised  and  enlarged  (1901).     Ifi  Preparation. 


PUBLICATIONS   OF   WILLIAM    WOOD    &   COMPANY 


Spencer,  Walter  G.,  M.B.,  M.S.,  F.R.C.S.,  London. 

OUTLINES  OF  PRACTICAL  SURGERY.  One  volume  of  704  pages, 
8vo,  well  illustrated  by  wood -engravings.     Extra  muslin,  $5.00  7iet. 

Starr,  M.  Allen,  M.D.,  Ph.D., 

Professor  of  Diseases  of  the  Mind  and  Nervous  System  ;  College  of  Physicians  aad  Surgeons,  New- 
York. 

FAMILIAR  FORMS  OF  NERVOUS  DISEASE.  With  illustrations, 
diagrams,  and  charts.     8vo,  350  pages,  muslin,  $2.50  iiet. 

Steel,  J.  H.,  M.D. 

OUTLINE  OF  EQUINE  ANATOMY.  A  Manual  for  the  use  ot  Veteri- 
nary Students  in  the  Dissecting  Room.  i2mo,  312  pages,  muslin,  $2.50 
net. 

Stewart,  R.  W.,  fl.D.,  M.R.C.S., 

Pittsburg. 

THE  DISEASES  OF  THE  MALE  URETHRA.  One  volume  of 
229  pages,  post-octavo,  illustrated  by  numerous  wood-engravings.  Mus- 
lin, $2.25  net ;  flexible  morocco,  $3.00  net.  {Medical  Practitioners* 
Library.) 

Sternberg,  George  M.,  M.D.,  F.R.M.S., 

Surgeon-General  U.  S.  Army;  Director  of  the  Hoagland  Laboratory,  Brooklyn,  N.  Y.;  Honorary 
Member  of  the  Epidemiological  Society  of  London,  of  the  Royal  Academy  of  Medicine  of  Rome, 
of  the  Academy  of  Medicine  of  Rio  de  Janeiro,  of  the  American  Academy  of  Medicine,  etc. 

A  TEXT-BOOK  OF  BACTERIOLOGY.  One  volume,  large  8vo,  693 
pages,  illustrated  by  heliotype  and  chromo-lithographic  plates  and  two 
hundred  engravings  in  black  and  colors.  Second  Revised  Edition. 
Extra  muslin,  $5.00  net ;  brown  sheep,  $5.75  net. 

IMMUNITY:  PROTECTIVE  INOCULATIONS  IN  INFECTIOUS 
DISEASES  AND  SERUM-THERAPY.  Post  8vo,  332  pages,  muslin, 
$2.00  net;  flexible  morocco,  $2.75  net. 

Stevenson,  W.  F.,  A.B.,  M.B.,  M.Ch.  Dublin  Univ., 

Surgeon-Colonel  (Army  Medical  Staff,  British  Army) ;  Professor  of  Military  Surgery,  Army  Medi- 
cal School,  Netley. 

WOUNDS  IN  AVAR;  THE  MECHANISM  OF  THEIR  PRODUC- 
TION AND  THEIR  TREATMENT.  One  volume,  8vo,  450  pages, 
profusely  illustrated  by  half-tone  plates,  etc.,  muslin.     Price,  $4.00  net. 

Stewart,  T.  Grainger,  M.D., 

FeUow  of  the  Royal  CoUege  of  Physicians ;  Physician  to  the  Royal  Infirmary,  etc.,  etc. 

CLINICAL  LECTURES  ON  ALBUMINURIA.  8vo,  261  pages, 
muslin,  $2.00  net. 

Supplement    to    the    International    Encyclopedia    of 
Surgery. 

One  imp.  Svo  volume,  of  1,136  pages,  illustrated.  Muslin,  $6.00  ;  leather, 
$7.00;  half  morocco,  $8.00.     Circular  on  application. 


PUBLICATIONS   OF   WILLIAM    WOOD   &   COMPANY.  21 

Surgery,  International  Encyclopedia  of. 

By  Various  Authors.  Edited  by  Dr.  John  Ashhurst,  Jr.  Seven  volumes, 
including  Supplement,  imp.  8vo,  of  about  950  pages  each,  muslin,  $6.00  ; 
leather,  $7.00  ;  half  morocco,  $8.00.    Send  for  circulars.     (Subscription.) 

Tait's,  Lawson,  Perineal  Operations,    see  ncKay. 
Thomas,  John  J. 

Revised  and  Enlarged  by  WILLIAM  H.  S.  WOOD,  Esq. 

THE  AMERICAN  FRUIT  CULTURIST.  Twentieth  edition.  Post 
8vo,    784  pages,  illustrated  by  800  wood-engravings.     Muslin,  $2.50. 

Thomson,  H.  Campbell,  M.D.  (Lond.),  M.R.C.P. 

AN  INTRODUCTION  TO  DISEASES  OF  THE  NERVOUS  SYS- 
TEM.    Octavo,  131  pages,  illustrated.     Price,  $1.00  ?iet. 

Thomson,  St.  Clair,  M.D.,  M.R.C.P.  (Lond.),  F.R.C.S., 
Eng. 

THE  CEREBRO-SPINAL  FLUID  ;  Its  Spontaneous  Escape  from 
THE  Nose.     Octavo  volume,  147  pages.     Price,  $1.50  net. 

Treves,  Frederick,  F.R.C.S., 

Consulting  Surgeon  to  and  Emeritus  Professor  of  Surgery  at  th.e  London  Hospital. 

INTESTINAL  OBSTRUCTION.  Its  varieties  with  their  Pathology, 
Diagnosis,  and  Treatment.  One  volume,  8vo,  576  pages.  Illustrated  by 
118  half-tone  cuts.  New  and  Revised  Edition.  Price,  muslin  binding, 
$4.00  net. 

Turner,  Dawson,  V.A.,  M.D., 

Lecturer  on  Medical  Physics  and  Electro-Therapeutics,  Surgeons'  Hall,  Edinburgh. 

A  MANUAL  OF  PRACTICAL  MEDICAL  ELECTRICITY.  One 
volume,  8vo,  351  pages,  profusely  illustrated  by  wood  engravings  and 
full-page  half-tones,  ^2.50  7iet. 

Twentieth  Century  Practice. 

AN  INTERNATIONAL  ENCYCLOPEDIA  OF  MODERN  MEDICAL 
SCIENCE.  By  Leading  Authorities  of  Europe  and  America.  Edited 
by  Thomas  L.  Stedman,  M.D.,  New  York  City.  Twenty  volumes, 
royal  8vo.  Muslin,  $5.00  ;  leather,  $6.00;  half  morocco,  $7.50  per 
volume.     (Subscription.)     Circulars  on  application. 

Valentine,  Ferd.  C,  M.D., 

Professor  of  Genito-TJrinary  Diseases,  New  York  School  of  Clinical  Medicine,  etc.,  etc. 

THE  IRRIGATION  TREATMENT  OF  GONORRHOEA,  ITS  LOCAL 
COMPLICATIONS  AND  SEQUELAE.  One  volume  of  227  pages, 
8vo,  profusely  illustrated.    Extra  muslin,  ^2.00  net. 

Vest=  Pocket  fledical  Dictionary,    see  Buck. 


PUBLICATIONS   OF   WILLIAM    WOOD   &   COMPANY. 


Veterinarian's  Visiting  List  and  Call=Book. 

By  D.  P.  YoNKERMAN,  D.V.S.  Twenty  pages  of  closely  printed  matter 
essential  to  the  veterinarian,  and  blank  pages,  specially  arranged,  for 
full  record  of  cases,  etc.,  etc.  Bound  in  black  morocco  cover,  with  flap 
and  pocket — pocket-book  style,  $1.25  tiet. 

Visiting  List  (Medical  Record),  or  Physician's  Diary. 

Containing,  besides  the  diary,  much  useful  information  on  many  subjects  of 
daily  interest  to  the  physician.  Prices  :  For  thirty  patients  a  week; 
handsome  red  or  black  leather  binding,  with  or  without  dates,  $1.25, 
for  sixty  patients  a  week,  same  style,  with  or  without  dates,  $1.50. 

Removable,  fitting  into  black  sealskin  and  calf  wallets,  from  $2.50  to  $4. 00. 
Send  for  a  circular.     Prices  all  net. 

Wall^er,  Norman,  M.D., 

Assistant  Physician  for  Diseases  of  the  Skin  to  the  Royal  Edinbui'gh  Infirmary. 

AN  INTRODUCTION  TO  DERMATOLOGY.  One  volume  of  263 
pages,  8vo.  With  a  frontispiece  and  29  exquisite  chromo-lithographic 
plates,  besides  34  illustrations  in  the  text.     Price,  muslin,  $3.00  net. 

Walsh,  David,  M.D., 

Edinburgh.  Physician,  Weston  Skin  Hospital,  London  ;  Honorary  Secretary,  London  Roentgen 
Society,  London. 

PREMATURE  BURIAL;  FACT  AND  FICTION.  8vo,  49  pages, 
50  cents  net. 

EXCRETORY  IRRITATION,  AND  THE  ACTION  OF  CERTAIN 
INTERNAL  REMEDIES  ON  THE  SKIN.  One  volume,  8vo,  76 
pages,  75  cents  net. 

Walsham,   W.  J.,   H.B.,  C.H.  Aberd.,  F.R.C.S.  Eng., 

Senior  Assistant-Surgeon,  Lecturer  on  Surgery,  and  Surgeon-in-Charge  of  the  Orthopedic  De- 
partment, St.  Bartholomew's  Hospital,  etc. 

NASAL  OBSTRUCTION;  THE  DIAGNOSIS  OF  THE  VARIOUS 
CONDITIONS  CAUSING  IT,  AND  THEIR  TREATMENT.     362 

pages,  profusely  illustrated,  8vo,  muslin,  $2.50  net. 

Walsham  and 

Hughes,  Wm.  Kent,  H.B.  Lond.,  fl.B.  Helb., 
n.R.C.S.  Eng.,  L.R.C.P.  Lond., 

Orthopedic  Surgeon,  St.  Vincent's  Hospital ;  Assistant  Surgeon,  Children's  Hospital,  Melbourne. 

THE  DEFORMITIES  OF  THE  HUMAN  FOOT,  WITH  THEIR 
TREATMENT.  558  pages,  post  8vo,  profusely  illustrated  by  296 
engravings,  muslin,  $4.00  net. 

Warren,  J.  Collins,  M.D., 

Assistant  Professor  of  Surgery,  Harvard  University ;  Surgeon  to  the  Massachusetts  General 
Hospital ;  Member  American  Surgical  Association ;  Honorary  Fellow  Philadelphia  Academy  of 
Surgery. 

THE  HEALING  OF  ARTERIES  AFTER  LIGATURE  IN  MAN 
AND  ANIMALS.  8vo,  184  pages.  Superbly  illustrated  with  twelve 
full-page  plates  in  black  and  colors.     Muslin,  $2.75  net. 


PUBLICATIONS    OF   WILLIAM   WOOD   &   COMPANY.  23 

Weiss,  Ludwig,  M.D., 

AttendiDS  Physician  to  the  Genito-Urinary  and  Skin-Service,  German  Poliklinik  ;  Dermatologist  to 
the  Hebrew  Orphan  Asylum,  New  York,  etc. 

A  Translation,  with  notes  and  additions,  of 

CHRONIC    URETHRITIS    OF    GONOCOCCIC    ORIGIN.      By   J. 

De  Keersmaecker,  Centraalklinik  of  Antwerp  ;  and  J.  Verhoogen, 
University  of  Brussels.  Small  8vo,  297  pages,  with  illustrations  and 
four  full-page  plates  by  chromo-lithography,  showing  ^urethroscopic 
appearances.     Muslin,  $2.75  net. 

Wendt,  Edmund  C,  M.D., 

Curator  of  St.  Francis  Hospital ;  Pathologist  and  Curator  of  the  New  York  Infant  Hospital,  etc. 

A  TREATISE  ON  CHOLERA.  Edited  and  prepared  in  Association 
with  John  C.  Peters,  M.D.,  New  York  ;  John  B.  Hamilton,  M.D., 
Surgeon-General  U.  S.  Marine  Hospital  Service,  and  Ely  McClellan, 
M.D.,  Surgeon  U.  S.  Army.  8vo,  503  pages,  illustrated  with  maps 
and  engravings,  muslin,  $2.50  net. 

Whittaker,  J.  T.,  M.D.,  LL.D., 

Professor  of  the  Theory  and  Practice  of  Medicine,  Medical  College  of  Ohio,  etc.,  etc. 

A  PRACTICE  OF  MEDICINE,  PREPARED  FOR  STUDENTS  AND 
PRACTITIONERS.  8vo,  700  pages,  illustrated,  muslin,  $4.75 
?iet ;  leather,  $5.50  net. 

Williams,  J.  W.  Hume, 

Of  the  Middle  Temple,  Barrister-at-Law,  London. 

UNSOUNDNESS  OF  MIND  IN  ITS  LEGAL  AND  MEDICAL 
CONSIDERATIONS.  A  complete  reprint  of  this  important  work. 
Svo,  166  pages,  muslin,  $1.50  net. 

Williams,  W.  Roger,  F.R.C.S.  Bristol,  Eng. 

UTERINE  TUMORS  ;  Their  Pathology  and  Treatment.  Octavo, 
373  P3^ges,  with  many  illustrations  in  the  text.    Muslin,  $3.00  7iet, 

Witthaus,  R.  A.,  A.M.,  M.D., 

Professor  of  Medical  Chemistry  and  Toxicology  in  the  University  of  Vermont ;  Member  of  the 
Chemical  Societies  of  Paris  and  Berlin,  etc. 

THE     MEDICAL     STUDENT'S     MANUAL      OF     CHEMISTRY. 

(American  Series  of  Medical  Text-Books.)  Fourth  revised  edition. 
556  pages  and  62  woodcuts,  muslin,  $3.25  net. 

ESSENTIALS  OF  CHEMISTRY  AND  TOXICOLOGY.  For  the 
Use  of  Students  in  Medicine.  Twelfth  edition.  (Wood's  Pocket 
Manuals.)     32mo,  319  pages,  muslin,  $1.00  net. 

GUIDE  TO  URINALYSIS  AND  TOXICOLOGY.  For  Students 
and  Practitioners.  Fourth  revised 'edition.  Oblong  i2mo,  interleaved, 
muslin,  $1.00  net. 


24  PUBLICATIONS    OF   WILLIAM    WOOD   &   COMPANY.  i 

Witthaus,  R.  A.,  M.D.,  and  Becker,  T.  C,  Esq.  ; 

With  a  staff  of  Collaborators. 

MEDICAL  JURISPRUDENCE  AND  TOXICOLOGY.  Four  vol-  ^ 
umes,  8vo,  bound  in  muslin  and  leather,  at  $5.00  and  $6.00  respectively,  j 
(Subscription.)     Circulars  on  application.  ;' 

Wood's  Household  Practice  of  Medicine,  Hygiene,  and 
Surgery.  j 

A  Practical  Treatise  for  the  Use  of  Families,  Travellers,  Seamen,  Miners,  i 

and   others.      By  Various   Authors.      8vo,    765    pages,    illustrated   by  : 

colored  lithographic  plates   and   five   hundred   fine   wood-engravings,  i 

Muslin,  $5.00  net.  J 

i 

Wood's  Index  Rerum.  ; 

The  finest  arrangement  yet  devised  for  all  ready  record  and  reference 
purposes.     For  professional  use  in  recording  your  cases,  or  in  grouping     \ 
your  cases  from  your  case  books.      Patent   index.      Vowel    arrange- 
ment.    Bound  for  permanency  in  ledger  binding,  $5.00  net  i 

j 

Wood's  Pocket  Lexicon.  i 

See  ROOSA.  i 

■[. 
Yonkerman,    D.    P.        see  veterinarian's  Visiting  List. 

Ziegler,  Ernst, 

Professor  of  Pathological  Anatomy  and  of  General  Pathology  in  the  University  of  Freiburg.  ' 

TEXT-BOOK  OF  GENERAL    PATHOLOGY.     Translated  from   the     \ 
Ninth  German  edition,  under  the  editorship  of  Albert  H.  Buck,  M.D., 
New  York,  by  a  select  corps  of  specialists.     Royal  8vo,  618  pages,  with 
542  illustrations  in  black  and  numerous  exquisite  tints,  and  a  chromo-     i 
lithographic  plate.     Muslin,  $5.00  net;  leather,  $5.75  net.  ' 

i 
i 

Ziemssen,  H.  von,  M.D.  Munich.  j 

CYCLOPEDIA  OF  THE  PRACTICE  OF  MEDICINE.  By  Vari-  | 
ous  Authors.  Complete  in  twenty  volumes,  royal  8vo.  A  few  sets  j 
left.     Prices  on  application. 


